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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 UST spill containment structures. The completed form and <br />printouts from tests (f applicable), should be provided to the facility owner/operator, for submittal to the local regulatory agency. <br />n r.rr Tmv TXT1U"0?%4 A'TT"NT <br />Facility Name: FOOD MART GAS VALERO- Date of Testing: 09-22-09 <br />Facility Address: 2185 EAST FREMONT STREET STOCKTON CALIFORNIA 95205 <br />Facility Contact: LAL Phone: 209-937-0195 <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (ifpresent during testing): SAN JOAQUIN CO JEFF FONG <br />,7 •rt, crrTNr_ rnNTRACTOR INFORMATION <br />Company Name: AFFORDA TEST 416 2"d 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 />II Credentials: ® [CC Service Tech. ® SWRCB Tank Tester II <br />I c.r.rr T nTTnv'vT TL'CTTNf' TN1[7"1 X4ATrMN <br />Test Method Used: ® Hydrostaticy v ❑ Vacuum ❑Other <br />Test Equipment Used: TAPE H2O <br />Equipment Resolution: 1/16 <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />Bucket Installation Type: <br />1 87 <br />F -1 -Direct Bury <br />Contained in Sump <br />2 91 <br />Direct Bury <br />®Contained in Sump <br />3 DIE <br />E] Direct Bury <br />® Contained in <br />Sum <br />4 <br />E] Direct Bury <br />❑ Contained in <br />Sum <br />Bucket Diameter: <br />11 <br />1 I <br />I I <br />Bucket Depth: <br />12 <br />14 1/2 <br />11 1/2 <br />Wait time between applying <br />vacuum/water and start of test: <br />_ <br />- <br />- <br />- <br />Test Start Time (Tj): <br />900 <br />900 <br />900 <br />Initial Reading (Rj): <br />11 <br />13 1/2 <br />10 1/4 <br />Test End Time (TF): <br />1000 <br />1000 <br />1000 <br />Final Reading (RF): <br />11 <br />13 1/2 <br />10 1/4 <br />Test Duration (TF — Ti): <br />1 HOUR <br />I HOUR <br />I HOUR <br />Change in Reading (RF - Rj): <br />0 <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />Test Result: <br />0 <br />® Pass ❑Fail <br />0 <br />®Pass ❑ Fail <br />0 <br />® Pass ❑ Fail <br />0 <br />❑ Pass ❑Fail <br />Comments — (include information on repairs made prior to testing, ana r•ecommenaeajouow-trp jur/uueu 1U31,)j <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 />Date: 9-22-09 <br />Technician's Signature: 6 <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 />