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-4, <br />AECIFIVED <br />Spill Bucket Testing Report Form <br />JUN 2 jWffl, January 2006 <br />This form is intended for use by contractors performing annual testing of UST spill contai j p& eP&AGW and <br />printouts from tests (f applicable), should be provided to the facility owner/operator for s�i tt11 ��� agency. <br />1_ FACii.iTY 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 (fpresent 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 />Credentials': ® ICC Service Tech. ® SWRCB Tank Tester <br />A CPTT T RITCKFT TFfiTTNC. INF( RNIATION <br />Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: TAPE MEASURE, H2O Equipment Resolution: 1 r 16" <br />Identify Spill Bucket (By Tank <br />;`-umber, 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 />E] Contained in Sump <br />® Direct Bury <br />El Contained in <br />Sum <br />❑ Direct Bury <br />El Contained in <br />Sum <br />Bucket Diameter: <br />I l <br />11 <br />Bucket Depth: <br />14 <br />14 3/4 <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (TI): <br />1045 <br />1045 <br />Initial Reading (RI): <br />14 <br />14 <br />Test End Time (TF): <br />1 145 <br />1145 <br />Final Reading (RF): <br />14 <br />14 <br />Test Duration (TF — Tj): <br />H R <br />HR <br />HR <br />H R <br />Change in Reading (RF - Rj): <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 in/ormation on repairs made prior to 1,!Vi17,i�. crud t•erommendrdJollou-up /01. foiled 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 />