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SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intended for use by contractors performing annual testing of UST spill containment structures. The completed form and <br /> printouts from tests (if applicable)should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: COUNTRY MARKET Date of Testing: JUL 6, 2010 <br /> Facility Address: 1524 FRESNO AVENUE, STOCKTON, CA 95206 <br /> Facility Contact: MIKE EL/ASON Phone: (209)948-9412 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector (if present during testing): RAY VON FLUE <br /> 2. 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(Specify) <br /> Test Equipment Used: VISUAL Equipment Resolution: <br /> FN <br /> dentify Spill Bucket (By Tank <br /> umber, Stored Product, etc.) DIESEL FILL <br /> Bucket Installation Type: ® Direct Bury ❑ Direct Bury ❑ Direct Bury ❑ Direct Bury <br /> ❑ Contained in Sump ❑ Contained in Sump ❑ Contained in Sump ❑ Contained in Sump <br /> Bucket Diameter: 16.00" <br /> Bucket Depth: 14.25" <br /> Wait time between applying 10 MIN <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 1:45 PM <br /> Initial Reading(RI): 14.25" <br /> Test End Time(TF): 2:45 PM <br /> Final Reading(RF): 14.25" <br /> Test Duration(TF—Tj): 1 HR <br /> Change in Reading(RF-Rj): 0 <br /> Pass/Fail Threshold or Criteria: <br /> Test Result: 11 ® Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail <br /> Comments — (include information on repuirs made prior to testing, and recommended follow-up for failed tests) <br /> TEST WAS PERFORMED WITH AN ISOLATION TEST PLUG INSTALLED BELOW DRAIN VALVE INSIDE DROP TUBE <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> hereby certify that all the information contained in this report is true,accurate, and in full compliance with legal requirements. <br /> Technician's Signature: — v� Date: JUL 6, 2010 <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 />