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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 (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: SUPER CENTER MART Date of Testing: 6/11/12 <br />Facility Address: 701 E. CHARTER WAY STOCKTON, CA 95206 <br />Facility Contact: Swaran Phone: <br />Date Local Agency Was Notified of Testing :6/4/12 <br />Name of Local Agency Inspector (fpresent during testing): THUY <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: AFFORDA TEST 4162 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 />11 Credentials: ® ICC Service Tech. ® SWRCB Tank Tester 11 <br />3 QPTT.T. RTTrWF.T TFSTING INFORMATION <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 <br />1 <br />Bucket Installation Type: <br />® Direct Bury <br />❑Contained in Sump <br />❑ Direct Bury <br />❑Contained in Sump <br />® Direct Bury <br />❑ Contained in <br />SUMP <br />❑ Direct Bury <br />❑ Contained in <br />Sum <br />Bucket Diameter: <br />1 1 <br />1 1 <br />Bucket Depth: <br />14 <br />14 3/4 <br />Wait time between applying <br />vacuum/water and start of test: <br />-_ <br />Test Start Time (Tj): <br />0905 <br />0935 <br />Initial Reading (Rj): <br />13 3/4 <br />7 1/8 <br />Test End Time (TF): <br />1005 <br />1005 <br />Final Reading (RF): <br />13 3/4 <br />6 7/8 <br />Test Duration (TF —Tt): <br />HR <br />HR <br />HR <br />HR <br />Change in Reading (RF - Rt): <br />0 <br />- 1/4 <br />Pass/Fail Threshold or <br />Criteria: <br />Test Result: <br />® 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 />87 SPILL BUCKET FAILED ,COULDN'T LOCATE LEAK DURING TEST, Site will have Spill Repaired and retested. <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: 6-11-12 <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 />