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SWRCB,January 2006 Spill Bucket Testing Report Form This form is intended for use by contractors performing annual testing of UST spill containment structures. The completed form and printouts from tests(f applicable)should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: COUNTRY MARKET I Date of Testing: 3/2412011 Facility Address: 1524 FRESNO AVENUE, STOCKTON, CA 95206 Facility Contact: MIKE ELIASON Phone: (209)948-9412 Date Local Agency Was Notified of Testing: 2/15/2011 Name of Local Agency Inspector(f present during testing): STACEY RIVERA 2. TESTING CONTRACTOR INFORMATION Company Name: TANK-TEK ENVIRONMENTAL CORPORATION Technician Conducting Test: MIKE LAWRENCE Credentials': ®CSLB Contractor ® ICC Service Tech. ® SWRCB Tank Tester ❑ Other(Spec) License Number(s): 803705(CSLB Contractor)—1048103-UT(ICC Service Tech.)—90-1200(SWRCB Tank Tester) 3. SPILL BUCKET TESTING INFORMATION Test Method Used: ® Hydrostatic ❑Vacuum ❑ Other(Specify) Test Equipment Used: TAPE MEASURE Equipment Resolution: 1/16" Identify Spill Bucket Tank i 1 Number, Stored Product, etc.) DIESEL FILL Bucket Installation Type: ® Direct Bury ❑ Direct Bury ❑ Direct Bury ❑ Direct Bury ❑ Contained in Sump ❑Contained in Sump ❑ Contained in Sump ❑ Contained in Sump Bucket Diameter: 11.50" Bucket Depth: 14" Wait time between applying 0 vacuum/water and start of test: Test Start Time(Ti): 12:00 PM Initial Reading(Ri): 12.50" Test End Time(TF): 1:00 PM Final Reading(RF): 11" Test Duration(TF—Ti): 1 HR Change in Reading(RF-RI): 1.50" Pass/Fail Threshold or Criteria: 1/16" Test Result: ❑ Pass E Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail Comments—(include information on repairs made prior to testing, and recommended follow-up for failed tests) CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING I hereby certify that all the information contained in this report is true,accurate,and in full compliance with legal requirements. Technician's Signature: %lj��'Y �'rrz �'> Date: 3/24/2011 ' State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements may be more stringent.