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SWRCB, January 2006 Spill Bucket Testing Report Form This form is intended for use by contractors performing annual testing of UST spill containment structures. The completed form and printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: SHOP N GO I Date of Testing: 2-22-18 Facility Address: 4511 PACIFIC AVE STOCKTON CA 95207 Facility Contact: RAY Phone: Date Local Agency Was Notified of Testing: Name of Local Agency Inspector (fpresent during testing): ELIANA 2. TESTING CONTRACTOR INFORMATION Company Name: AFFORDA TEST 416 2" Street Galt, CA 95632 (209) 744-0112 Fax: (209) 744-0116 Technician Conducting Test: ❑ Ed Stearns ❑ Zane A. Nimmo ® David A. Winkler ❑ Felix G. Ramirez 8883080 -UT 8883064 -UT 8883059 -UT 8883072 -UT I Credentials': ® ICC Service Tech. ® SWRCB Tank Tester I 3. SPILL RIICKFT TESTING INFORMATION Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other Test Equipment Used: h20 and tape measure Equipment Resolution: 1/16 777777.z 7m Identify Spill Bucket (By Tank Number, Stored Product, etc. 1 87 2 91 3 4 Bucket Installation Type: ® Direct Bury F-1 Contained in Sump ® Direct Bury ❑Contained in Sump F-1DirectBury El Contained in Sump E] Direct Bury El Contained in Sum Bucket Diameter: 11 11 Bucket Depth: 14 16 Wait time between applying vacuum/water and start of test: Test Start Time (TI): 9 9 Initial Reading (RI): 14 16 Test End Time (TF): 10 10 Final Reading (RF): 14 16 Test Duration (TF — TI): 1HR IHR IHR Change in Reading (RF - RI): 0 0 0 Pass/Fail Threshold or Criteria: 1/16 1/16 1/16 Test Result: ® Pass ❑ Fail ® Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) OPW FLAPPERS 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. Technician's Signature: ' State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more stringent.