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AC ::EIVEL <br />JUN 2 6 2015 SWRCB, January 2006 <br />Spill Bucket Testing Report Form <br />This form is intended for use by contractors performing annual testing of UST spilEl��llF� UMENT7 ompleted form and <br />printouts from tests (tf applicable), should be provided to the facility owner/operator j!&F §IffMif?5Rb?tT� IrR&7 regulatory agency. <br />1_ FAC'TT.TTV INFORMATION <br />Facility Name: SUPER CENTER MART I Date of Testing: 6/8/15 <br />Facility Address: 701 E CHARTER WAY STOCKTON ,CA <br />Facility Contact: I Phone: <br />Date Local Agency Was Notified of Testing :5/30/15 <br />Name of Local Agency Inspector (f present during testing): FATINHA <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: ®Ed Stearns ❑ Lyle D. Nimmo ❑ Zane A. Nimmo ❑ David A. Winkler ❑ Felix G. Ramirez <br />5250492 -UT 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 MEASURE <br />Equipment Resolution: 1/16 <br />Identify Spill Bucket (By Tank <br />:Number, Stored Product, etc.) <br />1 87 <br />2 91 <br />3 <br />4 <br />Bucket Installation Type: <br />® Direct Bury <br />El 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 I <br />I 1 <br />Bucket Depth: <br />14 <br />143/4 <br />Wait time between applying <br />vacuum/water and start of test: <br />"fest Start Time (Ti): <br />900 <br />900 <br />Initial Reading (Rj): <br />13 <br />13 <br />rest End Time (TF): <br />1000 <br />1000 <br />Final Reading (RF): <br />13 <br />13 <br />Test Duration (TF — Ti): <br />I FIR <br />IHR <br />Change in Reading (RF -Rj): <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />1/16 <br />1/16 <br />1/16 <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 />1 hereby certify that all the information contained in this report is true, accurate, and in full compliance Nr ith legal requirements. <br />Technician's Signature:, = Date:6/8/15 <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 />