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3ECEIVED <br /> N O V 3 0 ' CB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intended for use by contractors performing annual testing of UST spill co W)NMgNTI�Q�.c�'�rm and <br /> printouts from tests(f applicable), should be provided to the facility owner/operator or su miVta p,X� f,&atory agency. <br /> 1. FACILITY INFORMATION UUCCII'''' <br /> Facility Name: FOOD MART AND GAS Date of Testing: 09-29-17 <br /> Facility Address: 2185 E FREMONT ST STOCKTON CA <br /> Facility Contact: I Phone: 925-993-5627 <br /> Date Local Agency Was Notified of Testing:09-18-17 <br /> Name of Local Agency Inspector(ifpresent during testing): SAN JOAQUIN CO <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2❑d Street Galt,CA 95632 (209)744-0112 Fax:(209)744-0116 <br /> Technician Conducting Test: ❑Ed Sterns ❑ Zane A.Nimmo ❑ David A.Winkler ® Felix G.Ramirez <br /> 814188-UT 8211269-UT 5263373-UT 5273934-UT <br /> Credentials': ❑ICC Service Tech. ❑ SWRCB Tank Tester <br /> 3. SPELL BUCKET TESTING INFORMATION <br /> Test Method Used: ®Hydrostatic ❑ Vacuum ❑Other <br /> Test Equipment Used: TAPE/H2O Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1 87 2 91 3 DIESEL 4 <br /> Number, Stored Product, etc.) <br /> ❑ Direct Bury ❑ Direct Bury ❑Direct Bury ❑ Direct Bury <br /> Bucket Installation Type: ®Contained in El Contained in <br /> ®Contained in Sump ®Contained in Sump Sum Sum <br /> Bucket Diameter: 11 11 11 <br /> Bucket Depth: 13 13 13 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(TI): 1045 945 1045 <br /> Initial Reading(RI): 13 13 13 <br /> Test End Time(TF): 1145 1045 1145 <br /> Final Reading(RF): 13 13 13 <br /> Test Duration(TF—Tj): 1 HOUR 1 HOUR 1 HOUR <br /> Change in Reading(RF-RI): 0 0 0 <br /> Pass/Fail Threshold or _ <br /> Criteria: <br /> Test Result: ® Pass ❑ Fail ® Pass ❑ Fail ® Pass ❑ Fail ❑ Pass ❑ Fail <br /> Comments—(include in on repairs made prior to testing, and recommended follow-up for failed tests) <br /> OPW BUCKETS <br /> INSTALLED NEW BUCKET O RINGS FOR BUCKETS TO PASS <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 /> Technician's Signature: Date:09-29-17 <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 />