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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 LIST spill containment structures. The completed form and <br /> printouts from tests (f 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 I Date of Test <br /> Facility Address: 419 SOUTH MAIN STREET MANTECA CALIFORNIA 95366 <br /> Facility Contact: BOBBY Phone: 209-239-7978 <br /> Date Local Agency Was Notified of Testing:04-14-14 <br /> Name of Local Agency Inspector(f present during testing): SAN JOAQUIN COG , , <br /> 2. TESTING CONTRACTOR INFORMATION DEP. iATMENT <br /> Company Name: AFFORDA TEST 4162 d 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 /> Credentials': ® ICC Service Tech. ® SWRCB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ® Hydrostatic ❑vacuum ❑ Other <br /> Test Equipment Used: TAPE/H2O Equipment Resolution: 1/16 <br /> Identify Spill Bucket(By Tank 1 87 2 91 3 DIE 4 <br /> Number, Stored Product, etc.) <br /> ® Direct Bury Direct Bury <br /> Bucket Installation Type: ® Direct Bury ® Direct Bury ❑ Contained in ❑ Contained in <br /> ❑Contained in Sump ❑ Contained in Sump SumpSum <br /> Bucket Diameter: 11 11 11 <br /> Bucket Depth: 14 14 14 <br /> Wait time between applying _ - - <br /> vacuum/water and start of test: <br /> Test Start Time(TI): 900 900 900 <br /> Initial Reading(RI): 13 1/2 13 13 1/2 <br /> Test End Time(TF): 1000 1000 1000 <br /> Final Reading(RF): 13 1/3 13 13 1/2 <br /> Test Duration(TF—TI): I HOUR 1 HOUR I HOUR <br /> Change in Reading(RF-Ri): 0 0 0 <br /> Pass/Fail Threshold or _ _ - <br /> Criteria: <br /> Test Result: ® Pass ❑Fail ® Pass El ® Pass El Fail ❑ Pass []Fail <br /> Comments— (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> PHIL TITE BUCKETS <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:05-15-14 <br /> ' State laws and regulations do not currently require testing to be ...;rformed by a qualified contractor. However, local requirements <br /> may be more stringent. <br />