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SWRCB, January 2006 Spill Bucket Testing Report Form This form is intended for use by contractors performing annual testing of UST split containment structures. The completed form and printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. 2. TESTING CONTRACTOR INFORMATION Company Name: AFFORDA TEST 416 2"d Street Galt, CA 95632 Technician Conducting Test: ® Zane A. Nimmo ❑ David A. Winkler #8883064 -UT #8883059 -UT Credentialsl: ® ICC Service Tech. ® SWRCB Tank Tester (209) 744-0112 Fax: (209) 744-0116 ❑ Felix G. Ramirez ❑ Ed Stearns #8883072 -UT #8883080 -UT 3. SPILL BUCKET TESTING INFORMATION Test Method Used: ®Hydrostatic E] Vacuum El Other 1. FACILITY INFORMATION Facility Name: Facility Address: FOOD MART GAS Date of Testing: 9/6/2018 2185 E. FREMONT STREET STOCKTON , CA 95205 Facility Contact: Identify Spill Bucket (By Tank Stored Product, etc. Phone: Date Local Agency Was Notified of Testing :8/22/2018 Name of Local Agency Inspector (if present during testing): STACY R. 2. TESTING CONTRACTOR INFORMATION Company Name: AFFORDA TEST 416 2"d Street Galt, CA 95632 Technician Conducting Test: ® Zane A. Nimmo ❑ David A. Winkler #8883064 -UT #8883059 -UT Credentialsl: ® ICC Service Tech. ® SWRCB Tank Tester (209) 744-0112 Fax: (209) 744-0116 ❑ Felix G. Ramirez ❑ Ed Stearns #8883072 -UT #8883080 -UT 3. SPILL BUCKET TESTING INFORMATION Test Method Used: ®Hydrostatic E] Vacuum El Other Test Equipment Used: TAPE MEASURE, H2O Equipment Resolution: 1/16" Identify Spill Bucket (By Tank Stored Product, etc. 1 87 2 3 91 4 DIESEL -Number, Bucket Installation Type: E] Direct Bury ® Contained in Sump ❑ Direct Bury ❑ Contained in Sump ❑ Direct Bury ® Contained in Sump ❑Direct Bury ®Contained in Sum Bucket Diameter: 11 11 11 Bucket Depth: 13 15 14 Wait time between applying vacuum/water and start of test: Test Start Time (Ti): 1030 1145 1030 Initial Reading (RI): 13 - 14 1/2 13 - Test End Time (TF): 1130 1245 1130 Final Reading (RF): 13 - 14 1/2 13 - Test Duration (TF — TI): H O U R Change in Reading (RF - Ri): 0 0 0 Pass/Fail Threshold or Criteria: Test Result: ® Pass ❑ Fail ❑ Pass ❑ Fail ® Pass ❑ Fail ® Pass ❑ Fail Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) CERTIFICATION OF TECIINICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING I hereby certify that all the information contained in this report is true, accurate, and in full compliance with legal requirements. Technician's Signature: Date: 9/6/2018 ' State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more stringent.