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or �. r 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 (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: HARDY'S GAS & FOOD I Date of Testing: 2/21/2017 Facility Address: 16 E. HARDING WAY STOCKTON , CA l 87 - EAST Facility Contact: HARDEEP Phone: 466-9516 4 DIESEL Date Local Agency Was Notified of Testing :1/30/2017 ❑ Direct Bury ®Contained in Sump Name of Local Agency Inspector ('(present during testing): STACY RIVERA MAR 2. TESTING CONTRACTOR INFORMATION 11 Company Name: AFFORDA TEST 416 211 Street Galt, CA 95632 (209) 744-01 Technician Conducting Test: ❑ Lyle D. Nimmo ® Zane A. Nimmo ❑ David A. Winkler ❑ Felix G. Ramirez 5249115 -UT 5263322 -UT 5263373 -UT 5273934 -UT Credentials': ® ICC Service Tech. ® SWRCB Tank Tester 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.) l 87 - EAST 2 87 - WEST 3 91 4 DIESEL Bucket Installation Type: ❑ Direct Bury ®Contained in Sump ❑ Direct Bury ®Contained in Sump ❑ Direct Bury ® Contained in Sump ❑ Direct Bury ® Contained in Sum Bucket Diameter: 1 1 11 I 1 11 Bucket Depth: 13 1/4 14 1/4 13 1/4 11 1/8 Wait time between applying vacuum/water and start of test: Test Start Time (Ti): 1000 1000 1000 1000 Initial Reading (RI): 11 1/2 11 1/2 11 1/2 11 1/8 Test End Time (TF): 1100 1100 1100 1100 Final Reading (RF): 11 1/2 11 1/2 11 -- 11 1/8 Test Duration (TF — TI): HR HR HR HR Change in Reading (RF - R,): 0 0 -1/2 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) 91 Spill bucket failed at bottom. To be repaired and retested by others. 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: 2-21-17 ' State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more stringent.