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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 (if applicable) should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: COUNTRY MARKET <br />I Date of Testing: JUNE 27, 2006 <br />Facility Address: 1524 FRESNO AVE, STOCKTON, CA 95206 <br />Facility Contact: DALE HEINZE <br />I Phone: 209-948-9412 <br />Date Local Agency Was Notified of Testing: <br />JUNE 16, 2006 <br />Name of Local Agency Inspector (ifpresent during testing): <br />MUNIAPPA NAIDU <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: TANK-TEK ENVIRONMENTAL CORPORATION <br />Technician Conducting Test: ROB NEIMEYER <br />Credentials: ® CSLB Contractor ❑ ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other (Spec) <br />License Number(s): 803705 <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other (Spec) <br />Test Equipment Used: <br />Equipment Resolution: <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc) <br />1 <br />DIESEL <br />2 <br />3 <br />4 <br />Bucket Installation Type: <br />® Direct Bury <br />❑ Contained in Sump <br />❑ Direct Bury <br />❑ Contained in Sump <br />❑ Direct Bury <br />❑ Contained in Sump <br />❑ Direct Bury <br />❑ Contained in Sump <br />Bucket Diameter: <br />10.50" <br />Bucket Depth: <br />11.50" <br />Wait time between applying <br />vacuum/water and start of test: <br />0 <br />Test Start Time (TI): <br />12:00 PM <br />Initial Reading (Rj): <br />11.50" <br />Test End Time (TF): <br />12:30 PM <br />Final Reading (RF): <br />11.50" <br />Test Duration (TF — TI): <br />30 MIN <br />Change in Reading (RF - RI): <br />0 <br />Pass/Fail Threshold or 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 follow-up for failed tests) <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />1 hereby certify that all the information contained in this report is true, accurate, and in full compliance with legal requirements. <br />Technician's Signature:!� r Date: <br />JUNE 27, 2006 <br />1 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 />