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RCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intended for use by contractors performing annual testing of UST spill cop�r" and <br /> r <br /> printouts from tests(if applicable), should be provided to the facility ownerloperatorfor or susu mitu nN atony agency. <br /> 1.FACILITY INFORMATION <br /> Facility Name: ONE STOP MARKET I Date of Testing: 12-04-17 <br /> Facility Address: 1151 W LOUISE AVE MANTECA CA 95336 <br /> Facility Contact: HARI Phone: 209-823-4081 <br /> Date Local Agency Was Notified of Testing:11-22-17 1 <br /> Name of Local Agency Inspector(ifpresent during testing): SAN JOAQUIN CO <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2"Street Galt,CA 95632 (209)744-0112 Fax:(209)744-0116 <br /> Technician Conducting Test: EJEd Stems F Zane A.Nimmo 0 David A.Winkler E Felix G.Ramirez <br /> 814188-UT 8211269-UT 5263373-UT 5273934-UT <br /> Credentials': El ICC Service Tech. E] SWRCB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: Hydrostatic El vacuum E]Other <br /> Test Equipment Used: TAPE/H2O Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1 87 2 91 3 DIESEL 4 <br /> Number, Stored Product, etc. E Direct Bury ®Direct Bury ®Direct Bury ❑Direct Bury <br /> Bucket Installation Type: E]Contained in Sump E]Contained in Sump D Contained in ❑ Contained in <br /> Sump Sump <br /> Bucket Diameter: 11 11 11 <br /> Bucket Depth: 15 15 15 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 830 830 830 <br /> Initial Reading(RI): 14 14 14 <br /> Test End Time(TF): 930 930 930 <br /> Final Reading(RF): 14 14 14 <br /> Test Duration(TF—Ti): I HOUR I HOUR I HOUR <br /> Change in Reading(RF-RI): 0 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: E Pass El Fail E Pass El Fail 0 Pass El Fail El Pass El Fail <br /> Comments— (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> OPW BUCKETS <br /> ALL BUCKETS HOLD 5 GALLON CAPACITY <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: Date:12-04-17 <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 />