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0 SWRCB, January 2006 <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 (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: COUNTRYSIDE MINI MART Date of Testing: 3-31-14 <br />Facility Address: 14971 N HWY 88 LODI CA <br />Facility Contact: Rupi/Bill Phone: 368-5380 <br />Date Local Agency Was Notified of Testing :2-17-14 <br />Name of Local Agency Inspector (if present during testing): Aris <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: AFFORDA TEST 4162 d Street Galt, CA 95632 (209) 744-0112 Fax: (209) 744-0116 <br />Technician Conducting Test: ❑ Lyle D. Nimmo ❑ Zane A. Nimmo ® David A. Winkler ❑ Felix G. Ramirez <br />5249115 -UT 5263322 -UT 5263373 -UT 5273934 -UT <br />I Credentials': ® ICC Service Tech. ® SWRCB Tank Tester <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: h20 and <br />tape measure <br />Equipment Resolution: 1/16 <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />1 87 <br />2 91 <br />3 DSL <br />4 <br />Bucket Installation Type: <br />® Direct Bury <br />El Contained in Sump <br />®Direct Bury <br />El Contained in Sump <br />® Direct Bury <br />El Contained in <br />Sum <br />❑ Direct Bury <br />❑ Contained in <br />Sum <br />Bucket Diameter: <br />11 <br />11 <br />11 <br />Bucket Depth: <br />11 <br />11.50 <br />11.50 <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (Ti): <br />9 <br />9 <br />9 <br />Initial Reading (Rj): <br />10 <br />11 <br />11 <br />Test End Time (TF): <br />10 <br />10 <br />10 <br />Final Reading (RF): <br />10 <br />11 <br />11 <br />Test Duration (TF — TI): <br />IHR <br />IHR <br />IHR <br />[:Change in Reading (RF - RI): <br />0 <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />1/16 <br />1/16 <br />1/16 <br />Test Result: <br />( Pass ❑ <br />Fail '' <br />Pass [:]Fail <br />Z <br />Pass ❑ Foil <br />❑ Pass ❑ Fail <br />Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />opw flappers <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: <br />Date 3-31-14 <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 />