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SWRCB, January 2006 <br />Spill Bucket Testing Report Form JUL 18 2016 <br />This form is intended for use by contractors performing annual testing of UST spill containment structz,TAF pvhtpleted form and <br />printouts from tests (f applicable), should be provided to the facility owner/operator for submitta146-t�hel4ocoY " aimy lzgency. <br />1. FACILITY INFORMATION <br />Facility Name: SUPER CENTER MART I Date of Testing: 6/20/2016 <br />Facility Address: 701 E. CHARTER WAY STOCKTON, CA 95206 <br />Facility Contact: Phone: <br />Date Local Agency Was Notified of Testing :5/26/16 <br />Name of Local Agency Inspector (f present during testing): STACY RIVERA <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: AFFORDA TEST 416 2°a 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 />II Credentials': ® ICC Service Tech. ® SWRCB Tank Tester <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br />Test F,quipment Used: TAPE MEASURE. H2O Equipment Resolution: I/16" <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />1 87 <br />2 <br />3 91 <br />4 <br />Bucket Installation Type: <br />® Direct Bury <br />❑Contained in Sump <br />El Direct Bury <br />El Contained in Sump <br />® Direct Bury <br />❑ Contained in <br />Sump <br />E] Direct Bury <br />El Contained in <br />Sum <br />Bucket Diameter: <br />11 <br />11 <br />Bucket Depth. <br />13 3/4 <br />13 3/4 <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (TI): <br />0925 <br />0925 <br />Initial Reading (RI): <br />12 3/4 <br />12 3/4 <br />Test End Time (TF): <br />1025 <br />1025 <br />Final Reading (RF): <br />12 3/4 <br />12 3/4 <br />Test Duration (TF — Ti): <br />HR <br />HR <br />HR <br />HR <br />Change in Reading (RF - RI): <br />0 <br />0 <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 />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: 6-20-16 <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 />