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SWRCB, January 2006 Spill Bucket Testing Report Form This form is intendedfor use by contractors performing annual testing of UST spill containment structures. Thg,q mpleted form and pr•intorrts from tests (if applicable), should be provided to the facility owner/operator for subm#l40bW&12Larllc(tlory agency. 1. FACILITY INFORMATION 2. TESTING CONTRACTOR INFORMATION Company Name: AFFORDA TEST 416 2°d 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 Credentials': ® ICC Service Tech. ® SWRCB Tank Tester 3. SPILL BUCKET TESTING INFORMATION Test Method Used: ®Hydrostatic ❑Vacuum El Other Comments — (inchrde information on repairs made prior to testing, and recommended folloiti Facility Name: ORLANDOS MARKET I Date of Testing: 07-1048 Facility Address: 18754 HWY 26 LINDEN, CA 95236 Facility Contact: BRANDON Phone: 209-887-1100 Date Local Agency Was Notified of Testing:06-2048 Name of Local Agency Inspector (f present during testing): SAN JOAQUIN CO. AARON 2. TESTING CONTRACTOR INFORMATION Company Name: AFFORDA TEST 416 2°d 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 Credentials': ® ICC Service Tech. ® SWRCB Tank Tester 3. SPILL BUCKET TESTING INFORMATION Test Method Used: ®Hydrostatic ❑Vacuum El Other Comments — (inchrde information on repairs made prior to testing, and recommended folloiti Test Equipment Used: TAPE / H2O Equipment Resolution: 1/16 Identify Spill Bucket (By Tank Number, Stored Product, etc. 1 87 2 91 3 DIESEL 4 ® Direct Bury ❑ Contained in Sump ❑ Direct Bury ❑ Contained in Sum Bucket Installation Type: ❑ Direct Bury ® Contained in Sump ❑ Direct Bury ® Contained in Sump Bucket Diameter: 11 11 11 Bucket Depth: 12 12 14 Wait time between applying vacuum/water and start of test: Test Start Time (TI): 1030 1030 1030 Initial Reading (RI): 11 11 13 Test End Time (TF): 1130 1130 1130 Final Reading (RF): 11 11 13 Test Duration (TF — TI): 1 HOUR 1 HOUR 1 HOUR Change in Reading (RF - Ri): 0 0 0 Pass/Fail Threshold or Criteria: Test Result: ® Pass [:]Fail ® Pass ❑ Fail ® Pass ❑ Fail ❑ Pass ❑ Fail -arp for failed tests) GAS IS PHIL TITS BUCKETS DIESEL IS OPW BUCKET 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:07-10-18 State laws and regulations do not currently require testing to be performed by a qualified contractor, However, local requirements may be more stringent.