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Spill Bucket Testing Report Form n c� RECEWEDnY2006 <br />This form is intended for use by contractors performing annual testing of UST spill containment struc'iti" Ae pleted form and <br />printouts from tests (if applicable), should be provided to the facility owner/operator for sub' Ito the local regulatory agency. <br />MVIRONI��? 7N1TAL <br />1. FACILITY INFORMATION kPAITU nr <br />Facility Name: SUPER CENTER MART Date of Testing: 6/18-13 <br />Facility Address: 701 E. CHARTER WAY STOCKTON, CA 95206 <br />Facility Contact: <br />Phone: <br />Date Local Agency Was Notified of Testing :5-17-13 <br />Name of Local Agency Inspector (if present during testing): <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 ® 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. SPILL BUCKET TESTING 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 />4 <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 />SumpSum <br />❑ Direct Bury <br />❑ Contained in <br />Bucket Diameter: <br />11 <br />11 <br />Bucket Depth: <br />16 <br />14 <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (Ti): <br />9 <br />9 <br />Initial Reading (Rj): <br />15 <br />12.75 <br />Test End Time (TF): <br />10 <br />10 <br />Final Reading (RF): <br />15 <br />12.75 <br />Test Duration (TF — Tj): <br />HR <br />HR <br />HR <br />HR <br />Change in Reading (RF - Rj): <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 TESTINGI hereby certify that all <br />the information contained in this report is true, accurate, and in full compliance with legal requirements. <br />Tecnician's Signature: W <br />Date: 6/18-13 <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 />