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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: JUN 30, 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: JUN 28, 2010 <br /> Name of Local Agency Inspector (if present during testing): ERIC <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANK-TEK ENVIRONMENTAL CORPORATION <br /> Technician Conducting Test: MIKE LAWRENCE <br /> Credentials': ® CSLB Contractor ® ICC Service Tech. ® SWRCB Tank Tester ❑ Other(Spec) <br /> License Number(s): 803705(CSLB Contractor)—1048103-UT(ICC Service Tech.)—90-1200(SWRCB Tank Tester) <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other(Spec) <br /> Test Equipment Used: VISUAL Equipment Resolution: <br /> Identify Spill Bucket(By Tank <br /> Number, 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: 11.50" <br /> Bucket Depth: 14.00" <br /> Wait time between applying 0 <br /> vacuum/water and start of test: <br /> Test Start Time(Tj): 2:15 PM <br /> Initial Reading(Rj): 12.50" <br /> Test End Time(TF): 3:15 PM <br /> Final Reading(RF): 12.00" <br /> Test Duration(TF—Tj): 1 HR <br /> Change in Reading(RF-Rj): -0.501, <br /> Pass/Fail Threshold or Criteria: <br /> Test Result: El Pass ® Fail El Pass E] Fail [:1 Pass E:1 Fail El Pass ❑ Fail <br /> Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> DIESEL SPILL BUCKET FAILED DUE TO DRAIN VALVE-- UNABLE TO REPAIR VALVE <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> 1 hereby certify that all the information contained in this report is true, accurate,and in full compliance with legal requirements. <br /> Technician's Signature: " � r' Date: JUN 30, 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 />