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SWRCB, January 2006 Spill Bucket Testing Report Form T his form is intended for use by contractors performing annual testing of UST spill containment structures. The completed form and printouts from tests (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. i11 7►1VA /V Y 1-61 Facility Name: STOCKTON GATE WAY 76 Date of Testing: 8-13-2009 Facility Address: 322 S CENTER ST STOCKTON CA Facility Contact: RON Phone: Date Local Agency Was Notified of Testing: Name of Local Agency Inspector (fpresent during testing): RAY 2. TESTING CONTRACTOR INFORMATION Company Name: AFFORDA TEST 4162 nd Street Galt, CA 95632 (209) 744-0112 Fax: (209) 744-0116 Technician Conducting Test: ❑ Lyle D. Nimmo ❑ Zane A. Nimmo ® David A. Winkler ❑ Felix G. Ramirez 5249115 -UT 5263322 -UT 5263373 -UT 5273934 -UT Credentials': ® ICC Service Tech. J® SWRCB Tank Tester 1I 3_ RPTT,T, RITCKF,T TESTING INFORMATION Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other Test Equipment Used: H2O & TAPE MEASURE Equipment Resolution: 1/16 Identify Spill Bucket (By Tank Number, Stored Product, etc.) 1 87 2 91 3 4 Bucket Installation Type:❑ ® Direct Bury ❑Contained in Sump ® Direct Bury El Contained in Sump ❑ Direct Bury Contained in Sump ❑ Direct Bury ❑ Contained in Sum Bucket Diameter: 1 1 i l Bucket Depth: 14 15 Wait time between applying vacuum/water and start of test: NA NA NA NA Test Start Time (Tj): 900 900 Initial Reading (Ri): 13 14 Test End Time (TF): 1000 1000 Final Reading (RF): 13 14 Test Duration (TF — Tj): 1 HR 1 HR 1 HR Change in Reading (RF - Rj): 0 0 O Pass/Fail Threshold or Criteria: 1/16 1/16 1/16 Test Result: ® Pass ❑ Fail Z Pass ❑ Fail I Z Pass ❑ Fail ❑ Pass ❑ Fail Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) 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: Date8-13-2009 State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more stringent.