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Spill Bucket Testing Report Form AUG 2 7 Z01b <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 (if applicable), should be provided to the facility owner/operator for sub&( C#RAMT*ulatory agency. <br />1. FACILITY INFORMATION HEALTH DEP4RTNAENT <br />Facility Name: <br />COUNTRY MARKET PLACE <br />Date of Testing: 03-2848 <br />Facility Address: <br />1789 W CHARTER WAY STOCKTON, CA <br />Facility Contact: <br />TJ <br />Phone: 209-535-1096 <br />Date Local Agency Was Notified of Testing :03-21-18 <br />Name of Local Agency <br />Inspector (if present during testing): SAN JOAQUIN CO. CEASAR <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: ❑ Ed Stearns ❑ Zane A. Nimmo ❑ David A. Winkler ® Felix G. Ramirez <br />8883080 -UT 8883064 -UT 8883059 -UT 8883072 -UT <br />Credentials': ❑ ICC Service Tech. ❑ SWRCB Tank Tester <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: ®Hydrostatic El Vacuum <br />❑Other <br />Test Equipment Used: TAPE / H2O <br />Equipment Resolution: <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc. <br />1 87 <br />2 91 <br />3 <br />4 <br />Bucket Installation Type: <br />® Direct Bury <br />❑ Contained in Sump <br />®Direct Bury <br />❑ Contained in Sump <br />E] Direct Bury <br />❑ Contained in <br />SumpSum <br />E] Direct Bury <br />❑ Contained in <br />Bucket Diameter: <br />11 <br />11 <br />Bucket Depth: <br />14 <br />14 <br />Wait time between applying <br />vacuum/water and start of test: <br />_ <br />Test Start Time (Tj): <br />1200 <br />1200 <br />Initial Reading (Rj): <br />14 <br />14 <br />Test End Time (TF): <br />1230 <br />1300 <br />Final Reading (RF): <br />7 <br />14 <br />Test Duration (TF — Tj): <br />30 MINS <br />1 HOUR <br />Change in Reading (RF - Rj): <br />7 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />Test Result: <br />❑ Pass ® Fail <br />® Pass ❑ Fail <br />❑ Pass ❑ Fail <br />❑ Pass ❑ Fail <br />Comments — (include information on repairs made prior to testing, and recommended follojv-trp for failed tests) <br />PHIL TITE BUCKETS <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:03-28-18 <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 />