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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 ( fapplicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1 . FACILITY INFORMATION <br /> Facility Name : EL DORADO FOOD MART Date of Testing : 8 - 1448 <br /> Facility Address : 1901 S ELDORADO ST, STOCKTON , CA 95206 <br /> Facility Contact : Phone : <br /> Date Local Agency Was Notified of Testing : 8/ 1 / 18 <br /> Name of Local Agency Inspector (if present during testing) : <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 . Ninnno ® 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 ❑ Vacuum ❑ Other <br /> Test Equipment Used : h20 and tape measure Equipment Resolution: 1 / 16 <br /> Identify Spill Bucket (By Tank 1 87 2 91 3 4 <br /> Number, Stored Product, etc. <br /> ❑ Direct Bury ❑ Direct Bury <br /> Bucket Installation Type : ® Direct Bury ® Direct Bury ❑ Contained in [j Contained in <br /> ❑ Contained in Sump ❑ Contained in Sump <br /> Sump Sum <br /> Bucket Diameter: 11 11 <br /> Bucket Depth: 13 13 <br /> j Wait time between applying <br /> vacinim/water and start of test : <br /> Test Start Time (TI) : 10 10 <br /> Initial Reading (Ri) : 12 12 <br /> f <br /> Test End Time (TF) : 11 11 <br /> E Final Reading (RF) : 12 12 <br /> i <br />( Test Duration (TF — Tr) : IHR IHR <br /> Change in Reading (RF - RI) : 0 0 0 <br /> Pass/Fall Threshold or 1 / 16 1 / 16 1 / 16 <br /> i Criteria : <br /> Test Result: ® Pass ❑ Fail ® Pass - ❑ Fail ❑ Pass [:] Fail ❑ Pass ❑ Fail <br /> Comments — (include information on repairs nude prior to testing, and reconnnended fWoli - up for failed tests) <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 : Date 84448 <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 />