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SWRCB, January 2006 Spill Bucket Testing Report Form This 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. 1. FACILITY INFORMATION Facility Name: STOP N SHOP Date of Testing: 6/29/2018 Facility Address: 1856 COUNTRY CLUB STOCKTON, CA 95204 Facility Contact: I Phone: Date Local Agency Was Notified of Testing: 6/27/2018 Name of Local Agency Inspector (f present during testing): STACY RIVERA 2. TESTING CONTRACTOR INFORMATION Company Name: AFFORDA TEST 4162 nd Street Galt, CA 95632 (209) 744-0112 Fax: (209) 744-0116 Technician Conducting Test: ❑ Ed Stearns ® Zane A. Nimmo ❑ David A. Winkler ❑ Felix G. Ramirez 8883080 -UT 8883064 -UT 8883059 -UT 8883072 -UT II Credentials': ® ICC Service Tech. ® SWRCB Tank Tester II 3. SPILL BUCKET TESTING INFORMATION Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other Test Equipment Used: TAPE MEASURE, H2O Equipment Resolution: 1/16" Identify Spill Bucket (By Tank Number, Stored Product, etc. 1 87 2 3 91 4 Bucket Installation Type: ® Direct Bury El Contained in Sump Direct Bu ❑ Bury El Contained in Sump ® Direct Bury El Contained in Sump El Direct Bury El Contained in Sum Bucket Diameter: 11 11 Bucket Depth: 13 - 13 1/4 Wait time between applying vacuum/water and start of test: Test Start Time (Ti): 1205 1205 Initial Reading (Ri): 11 3/4 12 - Test End Time (TF): 1305 1305 Final Reading (RF): 11 3/4 12 - Test Duration (TF — TI): HOUR HOUR Change in Reading (RF - RI): 0 0 Pass/Fail Threshold or Criteria: Test Result: ® Pass ❑ Fail ❑ Pass ❑ Fail ® Pass ❑ Fail ❑ Pass ❑ Fail Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) MEASURED 5 GALLONS 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: Date: 6/29/2018 1 State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more stringent.