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SWRCB , January 2006 Spill Bucket Testing Report Form This form is intendedfor 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 : Fast & Easy Morada #60 (Stockton) Date of Testing : 4/11 /19 Facility Address : 10878 N Highway 99 Stockton 95212 Facility Contact: Asim Phone : (707) 393-9859 Date Local Agency Was Notified of Testing : 3-21 -19 Name of Local Agency Inspector (if present during testing) : Stacy Rivera 2 . TESTING CONTRACTOR INFORMATION Company Name : Confidence UST Services , Inc, Technician Conducting Test: Timothy Capehart Credentials ' : CSLB Contractor DICC Service Tech. 0 SWRCB Tank Tester Other (Spec) License Number(s) : 804904 8414476 3 . SPILL BUCKET TESTING INFORMATION Test Method Used : E✓ Hydrostatic ❑ Vacuum ❑ Other Test Equipment Used : Lake Test Equipment Resolution : 0.0625" Identify Spill Bucket (By Tank 1 2 3 4 Premium- 1 Premium-2 Unleaded Diesel Number, Stored Product, etc) Bucket Installation Type : ® Direct Bury 0 Direct Bury 0 Direct Bury ® Direct Bury ❑ Contained in Sump ❑ Contained in Sump ❑ Contained in Sump ❑ Contained in Sump Bucket Diameter: 11 .0" 11 .0" 11 .0" 11 . 0" Bucket Depth: 11 .0" 12.5" 12.5" 12.5" Wait time between applying 5 min 5 mins 5 mins 5 mins vacuum/water and start of test: Test Start Time (TI ) : 1 :30pm 1 :30pm 2:30pm 1 :30pm Initial Reading (RI) : 11 .0" 12.0" 12.0" 12.0" Test End Time (TF) : 2 :30pm 2:30pm 3:30pm 2:30pm Final Reading (RF ) : 11 .5" 12.0" 12.0" 12. 0" Test Duration (TF — Ti ) : 60 mins 60 mins 60 mins 60 mins Change in Reading (RF - RI ) : 0.5" 0. 0" 0. 0" 0 . 0" Pass/Fail Threshold or 0.0625" 0. 0625" 0.0625" 0 .0625" Criteria: Test Result. ❑ Pass 0 Fail 0 :Pass ❑ Fail 0 Pass ❑ Fail 0 Pass ❑ Fail Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) The Premium 10 OPW fill spill bucket does not hold 5 gallons Due to being a direct buried OPW spill bucket we will have to return and break concrete to make riser adjustments , replace and retest the spill bucket. Unleaded OPW fill spill bucket failed hydrostatic test due to leaking fill cap. Replaced cap -and retested with pa s . 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. i Technician ' s Signature : Date : 4/11 /19 ' State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more stringent.