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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(if applicable), should be provided to the facility ownerloperatorfor submittal to the local regulatory agency. <br /> 1.FACILITY INFORMATION <br /> Facility Name: ELDORADO FOOD MART I Date of Testing: 8n117 <br /> Facility Address: 1901 S ELDORADO ST STOCKTON CA 95206 <br /> Facility Contact: VENUS Phone: <br /> Date Local Agency Was Notified of Testing:7/28/17 <br /> Name of Local Agency Inspector(ifpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Nlatne: AFFORDA TEST 416 2,d Street Galt,CA 95632 (209)744-0112 Fax:(209)744-0116 <br /> Technician: ®Ed Steams F-1 Zane A.Nimmo 0 David A.Winkler ❑ Felix G.Ramirez <br /> 5250492-UT 8211269 5263373-UT 5273934-UT <br /> Credentials': Z ICC Service Tech. Z S- CB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: Hydrostatic El Vacuum F1 Other <br /> Test Equipment Used: TAPE MEASURE Equipment Resolution: 1/16 <br /> Identify Spill Bucket(By Tank 1 87 2 91 3 4 <br /> Number, Stored Product, etc.) <br /> Direct Bury Direct Bury F�Direct Bury El Direct Bury <br /> Bucket Installation Type: El contained in El Contained in <br /> ❑ Contained in, Sump ❑ Contained in SUMP SUMP <br /> Sump <br /> Bucket Diameter: 11 11 <br /> Bucket Depth: 12 12 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 830 �830 <br /> Initial Reading(Rj): I 11 <br /> tl <br /> Test <br /> est End Time(—IF): 930 930 <br /> Final Readir-10(RF): 11 I I <br /> Test Duration(TF IHR lHR <br /> Change in Reading(RF-R,): 0 0 <br /> Pass/Fail Threshold or /16 1/16 1/16 <br /> Criteria: <br /> Test'Result , z pass, El fall, Z Pass El Fail El Pass El Fail ❑ pass CJFail <br /> Comments— (include information on repairs made prior to testing, and recommendedfollow-up for failed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby cznh ify that aill the information contained in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature:' <br /> Date:8-7-17 <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 />