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0 RECEIVED <br /> Spill Bucket Testing Report Form <br /> SEP 3 0 2WCB,January 2006 <br /> This form is intended for use by contractors performing annual testing of UST spill containment strut a �tFtorm and <br /> printouts from tests (if applicable), should be provided to the facility owner/operator fc[r,WKK u aattory agency. <br /> 1.FACILITY INFORMATION DEPARTMERf <br /> Facility Name: QUICK&EASY FOOD MART Date of Testing: 6/27/2016 <br /> Facility Address: 824 E. YOSEMITE AVE. MANTECA, CA 95336 <br /> Facility Contact: JITENDER Phone: <br /> Date Local Agency Was Notified of Testing:6/10/2016 <br /> Name of Local Agency Inspector(ifpresent during testing): Fatinah <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2nd Street Galt,CA 95632 (209)744-0112 Fax:(209)744-0116 <br /> Technician Conducting Test: Lyle D.Nimmo ® Zane A.Nimmo ❑ David A. Winkler ❑ Felix G. Ramirez <br /> 5249115-UT 5263322-UT 5263373-UT 5273934-UT <br /> Credentials': ® ICC Service Tech. ® SWRCB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ® Hydrostatic ❑Vacuum ❑ Other <br /> Test Equipment Used: TAPE MEASURE. H2O Equipment Resolution: 1/16" <br /> Identify Spill Bucket (By Tank 1 87 2 89 3 91 4 <br /> Number,Stored Product, etc.) <br /> ® Direct Bury ® Direct Bury ®Direct Bury E] Direct Bury <br /> Bucket Installation Type: ❑Contained in E] Contained in <br /> ❑ Contained in Sump ❑ Contained in Sump SUMP Sum <br /> Bucket Diameter: 11 11 11 <br /> Bucket Depth: 13 1/2 13 1/2 13 1/2 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Tt): 9:20 9:20 9:20 <br /> Initial Reading(111): 12 1/2 12 1/2 121/4 <br /> Test End Time(TF): 10:20 10:20 10:20 <br /> Final Reading(RF): 12 1/2 12 1/2 12 1/4 <br /> Test Duration(TF—Tj): HR HR HR HR <br /> Change in Reading IRF-Rj): 0 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: ® Pass ❑ Fail__L ®; Pass ❑ Fail ❑ Pass ❑Fail ❑ 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 < — Date:6-27-16 <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 />