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11 <br />0 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 />FACTI.TTV INFIIRMATION <br />Facility Name: ERNIE'S GENERAL STORE I Date of Testing: <br />Facility Address: 4407 E. WATERLOO RD. STOCKTON, CA 95215 <br />Facility Contact: ERNIE Phone: 931-2850 17 <br />Date Local Agency Was Notified of Testing :12/28/2016 <br />Name of Local Agency Inspector (if present during testing): ELENAtallgONMENTAL <br />uFA1TH UCr- <br />2. <br />Company Name: AFFORDA TEST 416 2"a Street Galt, CA 95632 (209) 744-0112 Fax: (209) 744-0116 <br />Technician Conducting Test: ❑ Lyle D. Nimmo ® Zane A. Nimmo ❑ David A. Winkler ❑ Felix G. Ramirez <br />5249115 -UT 5263322 -UT 5263373 -UT 5273934 -UT <br />Credentials': ® ICC Service Tech. E SWRCB Tank Tester II <br />1 QDn I RITKFT TFCTFN!_ DNFIIRMATIIIN <br />Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: TAPE MEASURE, H2O Equipment Resolution: 1/16" <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc. <br />1 87 <br />2 <br />3 91 4 DIESEL <br />Bucket Installation Type: <br />®Direct Bury <br />❑ Contained in Sump <br />El Direct Bury <br />❑ Contained in Sump <br />® Direct Bury ® Direct Bury <br />❑ Contained in ❑ Contained in <br />SumpSum <br />Bucket Diameter: <br />11 <br />I 1 11 <br />Bucket Depth: <br />11 1/4 <br />12 1/2 13 <br />Wait time between applying <br />vacuum/water and start of test: <br />_ __ <br />Test Start Time (Tj): <br />1430 <br />1430 1430 <br />Initial Reading (Ri): <br />11 1/4 <br />11 1/2 12 <br />Test End Time ('rF): <br />1530 <br />1530 1530 <br />Final Reading (RF): <br />11 1/4 <br />11 1/2 11 3/4 <br />Test Duration (TF — Ti): <br />HR <br />HR <br />HR HR <br />Change in Reading (RF -Ri): <br />0 <br />0 1/4" <br />Pass/Fail Threshold or <br />Criteria: <br />Test Result: <br />® Pass ❑ Fail <br />❑ Pass ❑ Fail <br />® Pass ❑ Fail ❑ Pass ® Fail <br />Comments — (include information on repairs made prior to testing, and recommended follow-up jor failed tests) <br />DIESEL BUCKET FAILED BUT HAD SOME INTERFERENCES <br />SITE CALLING MAINTENANCE AND THEY WILL TROUBLESHOOT <br />AND RETEST <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 <br />Date: 1-24-17 <br />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 />