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V[70 OCT , 2017 SWRCB, Jnuary 2006 Spill Bucket Testing Report -F YiLHEA TI -11 This form is intended for use by contractors performing annual testing of UST spill containment structures. The completed form and printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. 1_ FACILITY INFORMATION Facility Name: TRACY TRUCK STOP Date of Testing: 4-21-17 Facility Address: 3940 N TRACY BLVD TRACY ,CA - Facility Contact: DEBBIE Phone: Date Local Agency Was Notified of Testing : 3-15-17 Name of Local Agency Inspector (f present during testing): Aaron sjv 2. TESTING CONTRACTOR INFORMATION Company Name: AFFORDA TEST 416 2111 Street Galt, CA 95632 (209) 744-0112 Fax: (209) 744-0116 Technician: EEd Stearns ❑ Zane A. Nimmo E David A. Winkler E Felix G. Ramirez 5250492 -UT 5263322 -UT 5263373 -UT 5273934 -UT Credentials': E ICC Service Tech. E SWRCB Tank Tester 3. SPILL BUCKET TESTING INFORMATION Test Method Used: ❑ Hydrostatic ❑ Vacuum ❑ Other Test Equipment Used: TAPE MEASURE Equipment Resolution: 1/16 Identify Spill Bucket (By Tank Number, Stored B=ucket 1 87 2 9l 3 DIE WEST 4 DIE EAST Bucket installation Type: ® Direct Bury ❑ Contained in Sump ®Direct Bury ® Direct Bury El Con in ❑ Contained in Sump Sump E Direct Bury ❑ Contained in Sum Bucket Diameter: I 1 11 1 I 11 Bucket Depth: 12 121/2 12 12 Wait time between applying vacuum/water and start of test: — Test Start Time (Ti): 10 10 10 10 Initial Reading (Rj): 12 12 11 11 Test End Time (TF): I 1 11 11 11 Final Reading (RF): 12 12 11 11 Test Duration (TF — Ti): IHR IHR IHR 1 HR Change in Reading (RF -R,): 0 0 0 0 Pass/Fail Threshold or Criteria: 1/16 1/16 1/16 1/16 Test Result: E Pass ❑ Fail E Pass ❑ Fail E Pass ❑ Fail E Pass ❑ Fail Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) ALL PASSED 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: ' State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more stringent.