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REUz-1vjj[Do6 <br />Spill Bucket Testing Report Form APR 06 g15 <br />This form is intended for use by contractors performing annual testing of UST spill containment structures. The comp eted form and <br />printouts from tests (if applicable) should be provided to the facility owner/operator for submittal t* ME Y t At <br />1. FACILITY INFORMATION <br />Ncp�,14 r1QQ4QTU CHIT L <br />Facility Name: COUNTRY MARKET <br />Date of Testing: 311212015 <br />Facility Address: 1524 FRESNO AVENUE, STOCKTON, CA 95206 <br />Facility Contact: MIKE ELIASON <br />Phone: (209) 948-9412 <br />Date Local Agency Was Notified of Testing: 3114115 <br />Name of Local Agency Inspector (f present during testing): NONE PRESENT <br />TESTING CONTRACTOR INFORMATION <br />Company Name: TANK-TEK ENVIRONMENTAL CORPORATION <br />Technician Conducting Test: RICHARD THOMAS <br />Credentials: ® CSLB Contractor ❑ ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other (Spec) <br />License Number(s): 803705 (CSLB Contractor) — 5254736 -UT (ICC Service Tech.) — 06-1672 (SWRCB Tank Tester) <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other (Spec) <br />Test Equipment Used: VISUAL - TAPE MEASURE <br />Equipment Resolution: 1/16" <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />I L L <br />[�� <br />Bucket Installation Type: <br />❑ Direct Bury <br />® Contained in Sump <br />❑ Direct Bury <br />❑ Contained in Sump <br />❑ Direct Bury <br />❑ Contained in Sump <br />❑ Direct Bury <br />❑ Contained in Sump <br />Bucket Diameter: <br />12" <br />Bucket Depth: <br />14" <br />Wait time between applying <br />vacuum/water and start of test: <br />10 MIN <br />Test Start Time (Tj): <br />11:25 <br />Initial Reading (Ri): <br />12.50" <br />Test End Time (TF): <br />12:25 <br />Final Reading (RF): <br />12.50" <br />Test Duration (TF — Ti): <br />15 MIN <br />Change in Reading (RF - Ri): <br />0 <br />Pass/Fail Threshold or Criteria: <br />NO LOSS <br />NO LOSS <br />NO LOSS <br />NO LOSS <br />Test Result: <br />® Pass ❑ Fail <br />❑ Pass ❑ Fail <br />❑ Pass ❑ Fail <br />❑ Pass ❑ Fail <br />Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />I hereby certify that all the information contained in this report is true, accurate, and in full compliance with legal requirements. <br />Technician's Signature: vt^� Date: 311212015 <br />State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements <br />may be more stringent. <br />