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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: ARP Mini Mart Date of Testing: 03/31/2017 Facility Address: 25775 Patterson Pass Road, Tracey, CA 95377 Facility Contact: Nick Patel Phone: (510) 600-3360 Date Local Agency Was Notified of Testing :03/16/2017 R Fj Name of Local Agency Inspector (if present during testing): Victoria M. Avt( i J ZU1/ 2. TESTING CONTRACTOR INFORMATION Company Name: Confidence UST Services, Inc. ENVIRi NIMEN TAL HEALTH Technician Conducting Test: Tim Capehart PERMIT/SEMACES Credentials: ❑x CSLB Contractor ❑x ICC Service Tech. ❑SWRCB Tank Tester []Other (Specify) License Number(s): CSLB# 804904 ICC# 8414476 3. SPILL BUCKET TESTING INFORMATION Test Method Used: 0 Hydrostatic ❑ Vacuum ❑Other Test Equipment Used: Lake Test Equipment Resolution: 0.0625" Identify Spill Bucket (Br Turk 1V11111ber, Stored Pro( ucl, Plc'.) 1 T-1 Blue Slave 2 T-2 Blue Master 3 T-3 Blue Siphon 4 T-4 Gold Bucket Installation Type: E] Direct Bury Contained in Sump []Direct Bury ❑x Contained in Sum []Direct Bury ❑x Contained in Sump ❑Direct Bury ❑x Contained in Sump Bucket Diameter: 11.00" 11.00" 11.00" 11.00" Bucket Depth: 12.50" 10.00" 12.50" 10.00" Wait time between applying vacuum/water and start of test: 5 min. 5 min. 5 min. 5 min. Test Start Time (Tj): 9:00 am 9:00 am 9:00 am 9:00 am Initial Reading (Rl): 15.00" 11.50" 15.50" 12.00" Test End Time (TF): 10:00 am 10:00 am 10:00 am 10:00 am Final Reading (RF): 15.00" 11.50" 15.50" 12.00" Test Duration (TF — Tl): 60 min. 60 min. 60 min. 60 min. Change in Reading (RF - Rl): 0.00" 0.00" 0.00" 0.00" Pass/Fail Threshold or Criteria: 0.0625" 0.0625" 0.0625" 0.0625" Test Result: ® Pass ❑ Fail 29 Pass ❑ Fail X! Pass ❑ Fail X 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: t` - Date: 03/31/2017 State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more stringent.