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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 (cf applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1 _ FAC'TT.TTV INFORMATION <br />Facility Name: <br />COUNTRY CLUB FOOD AND FUEL I Date of Testing: AUGUST 27,2009 <br />Facility Address: <br />1856 COUNTRY CLUB STOCKTON CALIFORNIA <br />Facility Contact: <br />PHIL Phone: <br />Date Local Agency <br />Was Notified of Testing :08-24-09 <br />Name of Local Agency Inspector (if present during testing): SAN JOAQUIN CO <br />Z. ' Jbb l J N U L: V.N 1 HAt;1 V H uv r WUV1A 11VA <br />Company Name: AFFORDA TEST 416 2nd 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 />A V.P11.1r. 3RTTC`KFT TFCTTNC INFORMATION <br />Test Method Used: ® Hydrostatic ❑ vacuum Other <br />Test Equipment Used: TAPE H2O Equipment Resolution: 1/16 <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc. <br />1 87 <br />2 91 3 <br />4 <br />Bucket Installation Type: <br />® Direct Bury <br />E] Contained in Sump <br />Direct Bury <br />®Direct Bury El Contained in <br />F1 Contained in Sump Sump <br />E] Direct Bury <br />E] Contained in <br />Sum <br />Bucket Diameter: <br />11 <br />11 <br />Bucket Depth: <br />14 <br />14 <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (T,): <br />1300 <br />1300 <br />Initial Reading (RI): <br />13 <br />13 <br />Test End Time (TF): <br />1400 <br />1400 <br />Final Reading (RF): <br />13 <br />13 <br />Test Duration (TF — T): <br />1 HOUR <br />1 HOUR <br />Change in Reading (RF - RI): <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />0 <br />0 0 <br />0 <br />Te§t Result: , . <br />Pass ❑ Fail <br />® Pass [] Fair . Eass ❑ Fail <br />❑ Pass ❑Fail <br />Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) <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: U � Date: 8-27-09 <br />1 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 />9T00/£T00 (¢j <br />9TTO VVL 60Z XVd ZV:TT 60OZ/ZO/TT <br />