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Spill Bucket Testing Report Form JUL fV40$> January 2006 <br />This form is intended for use by contractors performing annual testing of'UST spill containrrpz tt s� tctures.`The tomplet' it and <br />printouts from tests (if applicable), should be provided to the facility owner/operator for sub t alto the local regulatory, agency. <br />1. FACILITY INFORMATION <br />Facility Name: GSG GAS & MART Date of Testing: 6-26-17 <br />Facility Address: 701 E. CHARTER WAY STOCKTON, CA 95206 <br />Facility Contact: Swaran Phone: 467-0305 <br />Date Local Agency Was Notified of Testing: 5-19-17 <br />Name of Local Agency Inspector (rf present during testing): SJC <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: AFFORDA TEST 416 2"1 Street Galt, CA 95632 (209) 744-0112 Fax: (209) 744-0116 <br />Technician Conducting Test: ❑ Ed Stearns ❑ Zane A. Nimmo ® David A. Winkler ❑ Felix G. Ramirez <br />8184188 5263322 -UT 5263373 -UT 5273934 -UT <br />V Credentials': ® ICC Service Tech. ® SWRCB Tank Tester II <br />3. 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 Sump <br />❑ 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 1 <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 (Tj): <br />12 <br />12 <br />Initial Reading (Ri): <br />14 <br />14 <br />Test End Time (TF): <br />I <br />1 <br />Final Reading (RF): <br />14 <br />14 <br />Test Duration (TF — Tj): <br />HR <br />HR <br />HR <br />HR <br />Change in Reading (RF - R1): <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />--t <br />Test Result: <br />®Pass El Fail <br />El Pass El Fail <br />®Pass El 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 />V--C--5--� <br />Technician's Signature .. 6-26-17 <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 />