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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 (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: MY MINI MART I Date of Testing: 6-25-13 <br /> Facility Address: 1756 N WILSON WAY STOCKTON CA <br /> Facility Contact: LAL Phone: <br /> Date Local Agency Was Notified of Testing: 5-17-13 <br /> Name of Local Agency Inspector(fpresent during testing): ELENA <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 4162 nd 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: h20 and tape measure Equipment Resolution: 1/16 <br /> Identify Spill Bucket(By Tank 1 87 2 91 3 4 <br /> Number, Stored Product, etc.) <br /> Lj Direct Bury ETDirect Bury <br /> Bucket Installation Type: ® Direct Bury ® Direct Bury ❑ Contained in EI Contained in <br /> ❑ Contained in Sump ❑ Contained in Sump SumpStun <br /> Bucket Diameter: 1 I I I <br /> Bucket Depth: 13.50 13.50 <br /> Wait time between applying - <br /> -vacuum/water and start of test: <br /> Test Start Time(Ti): 9 1010 <br /> Initial Reading(Ri): 13 12.75 <br /> Test End Time(TF): 10 1110 <br /> Final Reading(RF): 13 12.75 <br /> Test Duration(TF—Tj): IHR IHR <br /> Change in Reading(RF-Rj): 0 0 <br /> Pass/Fail Threshold or 1/16 1/16 <br /> Criteria: <br /> Test Result ® Pass ❑Fail Z Pass ❑ Fail ❑ Pass ❑Fail ❑ Pass ❑Fail <br /> Comments— (include information on repairs made prior to testing, and recommended follow-up for failed tests) <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: V �— Date: 6-25-2013 <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 />