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January 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intendedfor use by contractors performing annual testing of UST spill contaiqmei(tsg <br /> and <br /> printouts from tests(if applicable), should be provided to the facility ownerloperatorfor sjli wt6c,*l,rqgu aTry agency. <br /> 1.FACILITY INFORMATION <br /> Facility Name: ONE STOP MARKET 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 <br /> Name Local Agency Inspector(ii(present during testing): SAN JOAQUIN CO <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2,d Street Galt,CA 95632 (209)744-0112 Fax: (209)744-0116 <br /> Technician Conducting Test: DEd Stems ❑ Zane A.Nimmo 0 David A.Winkler E Felix G. Ramirez <br /> 814188-UT 8211269-UT 5263373-UT 5273934-UT <br /> Credentials': E] ICC Service Tech. Ej SWRCB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: Hydrostatic El vacuum El Other <br /> Test Equipment Used: TAPE H2O Equipment Resolution: <br /> �� <br /> Identify Spill Bucket(By Tank 1 87 2 91 3 DIESEL 4 <br /> Number, Stored Product, etc. <br /> E Direct Bury E Direct Bury E Direct Bury F-1 Direct Bury <br /> Bucket Installation Type: El Contained in Sump E]Contained in Sump F1 Contained in E] Contained in <br /> Sum 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): 1 830 830 830 <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: Pass [] Fail_L 0 Pass [:]Fail Pass ❑Fail ❑ Pass ❑Fail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> QPW 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 />