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RECEIVED <br /> JUN 2 0 2018 <br /> SWRCB,January 2006 <br /> ENVIRONMENTAL HEALTH Spill Bucket Testing Report Form <br /> MPA TA11FANd for use by contractors performing annual testing of UST spill containment structures. The completed form and <br /> printouts fi-onu tests(if applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Names: Country Market Place Date of Testing: 6/13/18 <br /> Facility Address: 1789 W.Charter Way Stockton,CA 95206 <br /> Facility Contact:TJ Phone: 209-941-2222 <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: ELITE IV CONTRACTORS <br /> Technician Conducting Test: Joe Bartholdi <br /> Credentials: CSLB Contractor X ICC Service Tech. SWRCB Tank Tester Other(Specify) <br /> License Number(s): 00042842 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: X Hydrostatic Vacuum Other <br /> Test Equipment Used:Tape Measure Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1 Phil Tite 87 2 3 4 <br /> Number, Stored Product, etc. <br /> Bucket Installation Type: X Direct Bury X Direct Bury X Direct Bury Direct Bury <br /> Contained in Sump Contained in Sump Contained in Sump Contained in Sum <br /> Bucket Diameter: 13 <br /> Bucket Depth: 14 1/2 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Tj): 10:OOAM <br /> Initial Reading(Ri): 13 1/2 <br /> Test End Time(TF): 11:OOAM <br /> Final Reading(RF): 13 1/2 <br /> Test Duration(TF—Ti): 1 <br /> Change in Reading(RF-Ri): 0 <br /> Pass/Fail Threshold or Pass <br /> Criteria: <br /> Test Result: X Pass ❑Fail Pass ❑Fail Pass ❑Fail ❑ Pass ❑Fail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> Cleaned drain Installed new gasket. <br /> Replaced swivel adaptor. <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:-6/13/18— <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 />