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' <br /> Sp l Bucket Testing Report Form SWRCB,January 2006 <br /> This form is intended for use by contractors performing annual testing of UST spill containment structures. The completed,form and <br /> printouts fi-om tests(f applicable), should be provided to the facility owner/operator for submittal to the local regulatmy agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: MANTECA ESPRESS MART I Date of Testing: 05-23-11 <br /> Facility Address: 419 SOUTH MAIN STREET MANTECA CA <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing . <br /> Name of Local Agency Inspector(f present during testing): SAN JOQUIN CO STACY <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 4162 nd 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 87A 2 91 3 DIE 4 <br /> Number, Stored Product, etc. <br /> Direct Bu Direct Bury Direct Bury <br /> Bucket Installation Type: ® Bury ® Direct Bury El Contained in <br /> yp ❑ Contained in Sump ❑ Contained in Sump ❑ Contained in <br /> Sum Sum <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): 908 908 908 <br /> Initial Reading(Ri): 13 1/8 13 5/8 13 7/8 <br /> Test End Time(TF): 1008 1008 1008 <br /> Final Reading(RF): 13 1/8 13 5/8 13 7/8 <br /> Test Duration(TF—Tj): I HOUR I HOUR 1 HOUR <br /> Change in Reading(RF-Rj): 0 0 0 <br /> Pass/Fail Threshold or _ <br /> Criteria: " <br /> Test Result: ® Pass ❑ Fail E Pass ❑ Fail ® Pass ❑ Fail ❑ Pass ❑ Fail <br /> Coin ments— (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:05-23-11 <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 />