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SWRCB , January 2006 <br /> Spill Bucket Testing Report Form <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 /> 0000000 <br /> Facility Name : ELDORADO FOOD MART Date of Testing: 2/ 13/2018 <br /> Facility Address : 2320 N. EL DORADO STREET STOCKTON , CA 95204 <br /> Facility Contact: I Phone : <br /> Date Local Agency Was Notified of Testing : 1/22/2018 <br /> Name of Local Agency Inspector (f present during testing) : STACY <br /> 2 . TESTING CONTRACTOR INFORMATION <br /> Company Name : AFFORDA TEST 416 2" 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 /> 8211269 — UT 8211269 -UT 5263373 -UT 5273934-UT <br /> Credentials ' : ® ICC Service Tech. ® SWRCB Tank Tester <br /> 3 . SPILL BUCKET TESTING INFORMATION <br /> Test Method Used : ® Hydrostatic ❑ Vacuum ❑ Other <br /> Test Equipment Used : TAPE MEASURE, H2O Equipment Resolution: 1 / 16 " <br /> Identify Spill Bucket (By Tank 1 87 2 3 91 4 DIESEL <br /> Number, Stored Product, etc. <br /> ® Direct Bury ® Direct Bury <br /> Bucket Installation Type : ® Direct Bury ❑ Direct Bury ❑ Contained in ❑ Contained in <br /> ❑ Contained in Sump ❑ Contained in Sump SumpSum <br /> Bucket Diameter: 11 11 11 <br /> Bucket Depth: 14 13 3/4 12 1/2 <br /> Wait time between applying <br /> vacuum/water and start of test. <br /> Test Start Time (Ti) : 0925 0925 0925 <br /> Initial Reading (RI) : 13 - 12 3/4 11 3/4 <br /> Test End Time (TF) : 1025 1025 1025 <br /> Final Reading (RF) : 13 - 12 3/4 11 3/4 <br /> Test Duration (TF — TI) : HR HR HR <br /> Change in Reading (RF - Ri) : 0 0 0 <br /> Pass/Fail Threshold or _ __ <br /> Criteria: <br /> Test Result: ® Pass [:] Fail ❑ Pass ❑ Fail ® Pass [:] Fail ® Pass ❑ Fail <br /> 00000 <br /> Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> MEASURED 5 GALLONS <br /> !V7y, <br /> . 5 ... <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING [7 1 Fp n �. hl r �� HEALTH <br /> I hereby certify that all the information contained in this report is true, accurate, and in full compliance"wrtT� legal requirements . <br /> Technician ' s Signature : Date : 2/13/2018 <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 />