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FW. C F, <br />I E D <br />•A `VY^ <br />APR 19 2011 <br />SWRCB, January 2006 <br />Spill Bucket Testing Report Form <br />�NVlRONMEN� �+�-HEALTH <br />This form is intended for use by contractors performing annual testing of UST spill contMent s c(ayrg f p oWleted form and <br />printouts from tests (f applicable), should be provided to the facility owner/operator for submittal io the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: COUNTY MART GAS & FOOD 76 Date of Testing: 04-04-17 <br />Facility Address: 34243 SOUTH CHRISMAN ROAD TRACY CALIFORNIA 95376 <br />Facility Contact: SAHDU Phone: 209-832-8642 <br />Date Local Agency Was Notified of Testing :02-27-17 <br />Name of Local Agency Inspector (af present during testing): SAN JOAQUIN CO <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: AFFORDA TEST 4162 n1 Street Galt, CA 95632 (209) 744-0112 Fax: (209) 744-0116 <br />Technician Conducting Test: ❑ Ed Stearns ❑ Zane A. Nimmo ❑ David A. Winkler N Felix G. Ramirez <br />8184188 5263322 -UT 5263373 -UT 5273934 -UT <br />Credentials: N ICC Service Tech. N SWRCB Tank Tester <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: N Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: TAPE H2O <br />Equipment Resolution: 1/16 <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc) <br />1 87 <br />2 91 <br />3 DIE <br />4 DIE <br />Bucket Installation Type: <br />N Direct Bury <br />❑Contained in Sump <br />N Direct Bury <br />❑Contained in Sump <br />N Direct Bury <br />El Contained in <br />Sump <br />N Direct Bury <br />❑ Contained in <br />Sum <br />Bucket Diameter: <br />11 <br />11 <br />11 <br />11 <br />Bucket Depth: <br />13 <br />13 <br />14 <br />13 <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (Ti): <br />940 <br />940 <br />940 <br />940 <br />Initial Reading (Rj): <br />12 <br />12 <br />12 1/2 <br />13 <br />Test End Time (TF): <br />1040 <br />1040 <br />1040 <br />1040 <br />Final Reading (RF): <br />12 <br />12 <br />121/2 <br />13 <br />Test Duration (TF — Ti): <br />1 HOUR <br />1 HOUR <br />1 HOUR <br />1 HOUR <br />Change in Reading (RF - RI): <br />1 0 <br />0 <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />0 <br />0 <br />0 <br />0 <br />Test Result: <br />N Pass ❑ Fail <br />N Pass El Fail <br />N Pass El Fail <br />N 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 TESTED FOR 5 GALLONS = PASS <br />CERTIFICATION OF TECM%aCIAN 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: 4-4-17 <br />i 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 />