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! RE®EIVED <br />FEB 17 2017swRcB, January 2006 <br />Spill Bucket Testing Report Form <br />This form is intended for use by contractors performing annual testing of UST spiSt&MmmENFAL t1iMTgedform and <br />printouts from tests (ef applicable), should be provided to the facility owner/operator for subEOAM"P 'I jregulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: ERNIE'S GENERAL STORE I Date of Testing: 1/24/2017 <br />Facility Address: 4407 E. WATERLOO RD. STOCKTON, CA 95215 <br />Facility Contact: ERNIE Phone: 931-2850 <br />Date Local Agency Was Notified of Testing :12/28/2016 <br />Name of Local Agency Inspector (ifpresent during testing): ELENA <br />L. IEN 11174E UUtN IHAt-IUN 1P1rUn1VIA <br />Company Name: AFFORDA TEST 416 2"d 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. ® SWRCB Tank Tester <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: TAPE MEASURE, H2O <br />Equipment Resolution: 1/16" <br />Identify Spill Bucket (By Tank 1 87 <br />Number, Stored Product, etc. <br />2 <br />3 91 <br />4 DIESEL <br />Bucket Installation Type: ®Direct Bury <br />❑ Contained in Sump <br />❑Direct Bury <br />❑ Contained in Sump <br />® Direct Bury <br />❑ Contained in <br />SumpSum <br />® Direct Bury <br />❑ Contained in <br />Bucket Diameter. 11 <br />11 <br />11 <br />Bucket Depth: 11 1/4 <br />12 1/2 <br />13 <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (Ti): 1430 <br />1430 <br />1430 <br />Initial Reading (Ri): 11 1/4 <br />11 1/2 <br />12 <br />Test End Time (TF): 1530 <br />1530 <br />1530 <br />Final Reading (RF): 11 1/4 <br />11 1/2 <br />11 3/4 <br />Test Duration (TF—T1):HR <br />HR <br />HR <br />HR <br />Change in Reading (RF -Rt): 0 <br />0 <br />1/4" <br />Pass/Fail Threshold or <br />Criteria: <br />Test Result: ® 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 />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 />I hereby certify that all the information contained in this report is true, accurate, and in full compliance with legal requirements. <br />Technician's Signature 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 />