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. RECEIVED <br /> N Q v 0 7RCB,January 2006 <br /> Spill Bucket Testing Report Form I� <br /> This form is intended for use by contractors performing annual testing of UST spill cat� � form and <br /> printouts from tests(f applicable), should be provided to the facility ownerloperator f s !allok KeeAu atory agency. <br /> 1. FACILITY INFORMATION Y ��!! <br /> Facility Name: SUPER STORES INDUSTRIES Date of Testing: 10/6/2017 <br /> Facility Address: 16888 McK1NLEY AVE. LATHROP,CA 95330 <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing:CESAR <br /> Name of Local Agency Inspector(i(present during testing): 9/27/2017 <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2"`'Street Galt,CA 95632 (209)744-0112 Fax: (209) 744-0116 <br /> Technician Conducting Test: L] Ed Stearns Z Zane A.Nimmo ❑ David A. Winkler E] Felix G. Ramirez <br /> 8184188 8211269 5263373-UT 5273934-UT <br /> Credentials': U ICC Service Tech. ® SWRCB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: Z Hydrostatic ❑ Vacuum ❑ Other <br /> Test Equipment Used: TAPE MEASURE, H2O Equipment Resolution: 1116" <br /> Identify Spill Bucket(By Tank 1 WEST DIESEL 2 NEW OIL 3 WASTE OIL 4 EAST DIESEL <br /> Number, Stored Product, etc.) <br /> Z Direct Bury ❑ Direct Bury ❑ Direct Bury ❑ Direct Bury <br /> Bucket Installation Type: ® Contained in ❑ Contained in <br /> ❑ Contained in Sump ® Contained in Sump Sump Sum <br /> Bucket Diameter: 11 12 12 11 <br /> Bucket Depth: 13 112 13 13 12 112 <br /> Wait time between applying _- - -- <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 1309 1309 1309 1309 <br /> Initial Reading(Rr): 12 1/2 11 314 12 11 1/2 <br /> Test End Time(TF): 1409 1409 1409 1409 <br /> Final Reading(RF): 12 112 11 314 12 11 1/2 <br /> Test Duration(TF—TI): HR HR H R HR <br /> Change in Reading(RF-RI): 0 0 0 0 <br /> Pass/Fail Threshold or _ <br /> Criteria: <br /> Test Result: Z Pass ❑ Fail Pass ❑ Fail ED 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: 10-6-17 <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 />