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R , ► <br /> SWRCB,January 2006 <br /> Spill Bucket Testing Report FOFf11G 2 5 ?01h <br /> This form is intended far use by contractors performing annual testing of UST spilLompleted form and <br /> printouts from tests(ifapplicable), should be provided to the facility owner/operat� �lia igulatory agency. <br /> 1.FACILITY INFORMATION <br /> Facility Name: MY MIM MART Date of Testing: 06-25-15 <br /> Facility Address: 1756 NORTH WILSON WAY STOCKTON CA <br /> Facility Contact: SIGH I Phone: 775-421-9978 <br /> Date Local Agency Was Notified of Testing:05-26-15 <br /> Name of Local Agency Inspector(ifpresent during testing): SAN JOAQUIN CO CINDY <br /> 2.TESTING CONTRACTOR INFORMATION <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/H2O Equipment Resolution: 1/16 <br /> Identify Spill Bucket(By Tank 1 87 2 91 3 4 <br /> Number, Stored Product, etc. <br /> Direct Bury Direct Bury <br /> Bucket Installation Type: ®Direct Bury ®Direct Bury ❑Contained in ❑Contained in <br /> ❑ Contained in Sump ❑Contained in Sump Sump Sum <br /> Bucket Diameter: 11 I1 <br /> Bucket Depth: 14 14 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(T,): 900 900 <br /> Initial Reading(R,): 131/2 13 <br /> Test End Time(TF): 1000 1000 <br /> Final Reading(RF): 131/2 13 <br /> Test Duration(TF—T,): 1 HOUR l HOUR <br /> Change in Reading(RF-R,): 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Comments—(include information on repairs made prior to testing and recommended follow-up for failed tests) <br /> OPW BUCKETS <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:06-25-15 <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 />