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® ® CB Ja <br />RECEIVED <br />Spill Bucket Testing Report Form },'x�,qyy 2006 <br />This form is intended for use by contractors performing annual testing of UST spill containment struct <br />printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the <br />1. FACILITY INFORMATION <br />Facility Name: Country Club Valero I Date of Testing: 01-14-14 <br />Facility Address: 2575 COUNTRY CLUB BLVD STOCKTON CA <br />Facility Contact: Dave Phone: <br />Date Local Agency Was Notified of Testing :1-7-13 <br />Name of Local Agency Inspector (fpresent during testing): SAN JOAQUIN CO GARRETT <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: AFFORDA TEST 4162 d Street Galt, CA 95632 (209) 744-0112 Fax: (209) 744-0116 <br />Technician Conducting Test: ❑ Lyle D. Nimmo ❑ Zane A. Nimmo N David A. Winkler N Felix G. Ramirez <br />5249115 -UT 5263322 -UT 5263373 -UT 5273934 -UT <br />I Credentials': N ICC Service Tech. [0 SWRCB Tank Tester II <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: N Hydrostatic ❑ 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 />1 87 <br />2 91 <br />3 DIE <br />4 <br />Bucket Installation Type: <br />El Direct Bury <br />N Contained in Sump <br />El Direct Bury <br />®Contained in Sump <br />El Direct Bury <br />N Contained in <br />Sump <br />❑ Direct Bury <br />E] Contained in <br />Sum <br />Bucket Diameter: <br />11 <br />11 <br />11 <br />Bucket Depth: <br />13 <br />13 <br />13 <br />Wait time between applying <br />vacuum/water and start of test: <br />I <br />Test Start Time (Ti): <br />1200 <br />1200 <br />1200 <br />Initial Reading (Rj): <br />13 <br />13 <br />13 <br />Test End Time (TF): <br />1220 <br />1300 <br />1300 <br />Final Reading (RF): <br />11 <br />13 <br />13 <br />Test Duration (TF — TI): <br />1 HOUR <br />1 HOUR <br />1 HOUR <br />Change in Reading (RF - RI): <br />2 <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />Test Result: <br />❑ Pass <br />Fail <br />®' I ass ❑ <br />Fail <br />N Pass ❑ Fail <br />❑ Pass ❑ <br />Fail <br />Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />PHIL TITE BUCKETS <br />WAS UNABLE TO MAKE REPAIRS. NEEDS 87 NEW BUCKET, Central Petroleum will repair and retest. <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:#f --e7� <br />V Date:01-14-14 <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 />