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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 LIST 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 FArTI.TTV TNFnRMATION <br />Facility Name: SUPER CENTER MART I Date of Testing: 06-09-10 <br />Facility Address: 701-E CHARTER WAY STOCKTON CA 95206 <br />Facility Contact: Phone: <br />Date Local Agency Was Notified of Testing: _ <br />Name of Local Agency Inspector (fpresent during testing): SAN JOAQUIN CO RAY VON FLUE <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: AFFORDA TEST 4162 nd 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 />2 QDTT T RTT!'V'Vrr TFQTTN(_ TNIMPMATICIN <br />Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: TAPE/1-120 <br />Equipment Resolution: 1/16 <br />— _– <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />1 87 <br />2 91 <br />3 <br />4 <br />Bucket Installation Type: <br />® Direct Bury <br />❑ Contained in Sump <br />® Direct Bury❑ <br />❑ Contained in Sump <br />Direct Bury <br />❑ Contained in <br />Sump <br />❑ Direct Bury <br />❑ Contained in <br />Sum <br />Bucket Diameter: <br />11 <br />11 <br />Bucket Depth: <br />14 <br />13 <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (Ti): <br />915 <br />915 <br />Initial Reading (Ri): <br />13 1/8 <br />123/8 <br />Test End Time (TF): <br />1015 <br />1015 <br />_ <br />Final Reading (RF): <br />13 1/8 <br />117/8 <br />Test Duration (TF– Tj): <br />1 HOUR <br />1 HOUR <br />Change in Reading (RF- Rj): <br />0 <br />1/2 <br />Pass/Fail Threshold or <br />Criteria: <br />1/16 <br />1/16 <br />Test Result: <br />® Pass ❑ Fail <br />❑ Pass ® Fail <br />❑ Pass ❑ Fail <br />❑ Pass ❑ Fail <br />Comments — (include information on repairs made prior to testing, and recomnienaeajottow-upjor.tuueu <br />XXT A c T WART IP TO R F.P A TR RT ICKET_ l2la�� + �� - ��[ -� —U A V <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: <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 />