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"ECtIVEC' <br />U N 12 2 (�i��' January 2006 <br />Spill Bucket Testing Report Form <br />This form is intended for use by contractors performing annual testing of UST spill contarn"A"l ik 4letedformand <br />printouts from tests (f applicable), should be provided to the facility owner/operator for su8*r1tlhrte VrFlocal `regulatory agency. <br />1. FAC111TV INFORMATION <br />Facility Name: SUPER CENTER MART Date of Testing: 6-19-14 _ <br />Facility Address: 701 E. CHARTER WAY STOCKTON, CA 95206 <br />Facility Contact: Swaran Phone: <br />Date Local Agency Was Notified of Testing :5-30-14 <br />Name of Local Agency Inspector (if present during testing): STACY <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 X David A. Winkler ❑ Felix G. Ramirez <br />5249115 -UT 5263322 -UT 5263373 -UT 5273934 -UT <br />I Credentials': ® ICC Service Tech. ® SWRCB Tank Tester I <br />-I. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: TAPE MEASURE, H2O <br />Equipment Resolution: 1/16" <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 Sunup <br />❑ Direct Bury <br />E] Contained in Sump <br />® Direct Bury <br />❑ Contained in <br />Sump <br />❑ Direct Bury <br />El Contained in <br />Sum <br />Bucket Diameter: <br />1 I <br />I 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 (Ti): <br />1045 <br />1045 <br />Initial Reading (RI): <br />1 14 <br />14 <br />Test End Time (TF): <br />1145 <br />1145 <br />Final Reading (RF): <br />14 <br />14 <br />est Duration (TF — T,): <br />HR <br />HR <br />HR <br />-1/4 <br />HR <br />hange in Reading (RF - RI): <br />rPa- <br />0 <br />ss/Fail Threshold orriteria: <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 />TeTechnician's Signature: W Date: 6-19-14 <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 />