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SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intended for use by contractors performing annual testing of UST spill containment structures. The completed form and <br /> printouts from tests(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1.FACILITY INFORMATION <br /> Facility Name: MANTECA EXPRESS MART Date of Testing: 5/28/15 <br /> Facility Address: 419 S. MAIN STREET MANTECA, CA 95337 <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing:4/24/15 <br /> Name of Local Agency Inspector(f present during testing): MUNI a <br /> 2.TESTING CONTRACTOR INFORMATION <br /> 11 1 IL <br /> Company Name: AFFORDA TEST 4162 nd Street Galt,CA 95632 (209)744- a ; Blab <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 /> Credentials: M ICC Service Tech. ®SWRCB Tank Tester <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 1 87 2 3 91 4 DIESEL <br /> Number, Stored Product, etc. <br /> ®Direct Bury ❑ Direct Bury Direct Bury Direct Bury <br /> Bucket Installation Type: E]Contained in El Contained in Sump E] Contained in Sump ❑Contained in <br /> Sum Sum <br /> Bucket Diameter: 11 11 1 1 <br /> Bucket Depth: 15 15 15 112 <br /> Wait time between applying _- -- <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 1400 1400 1500 <br /> Initial Reading(Rj): 13 3/4 14- 13 1'4 <br /> Test End Time(TF): 1500 1500 1600 <br /> Final Reading(RF): 13 3/4 14- 13 14 <br /> Test Duration(TF—Ti): HR H R H R HR <br /> Change in Reading(RF-Rj): 0 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: 0 Pass [:] Fail ❑ Pass ❑ Fail ® Pass ❑ Fail ® 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 /> Technician's Signature �''�— Date:-5-28-15 <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 />