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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 spill containment structures. The completed form and printouts from tests (af applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: Country Club 76 Date of Testing: 5/19/09 Facility Address: 2175 Country Club Blvd, Stockton CA Facility Contact: Phone: Date Local Agency Was Notified of Testing :5-15-09 Name of Local Agency Inspector (if present during testing): San Joaquin County Garrett 2. TESTING CONTRACTOR INFORMATION Company Name: AFFORDA TEST 4162 nd Street Galt, CA 95632 (209) 744-0112 Fax: (209) 744-0116 Technician Conducting Test: ❑ Lyle D. Nimmo ❑ Zane A. Nimmo ❑ David A. Winkler ® Felix G. Ramirez 5249115 -UT 5263322 -UT 5263373 -UT 5273934 -UT I Credentials': ® ICC Service Tech. ® SWRCB Tank Tester I 3_ SPILL BUCKET TESTING INFORMATION Test Method Used: ® Hydrostatic ❑ vacuum ❑ Other Test Equipment Used: Tape/1-120 Equipment Resolution: Identify Spill Bucket (By Tank Number, Stored Product, etc.) 1 87 2 91 3 DIE 4 Bucket Installation Type: ❑ 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 13 13 Wait time between applying vacuum/water and start of test: 0 0 0 Test Start Time (Ti): 1500 1400 1400 Initial Reading (RI): 13 13 13 Test End Time (TF): 1600 1400 1400 Final Reading (RF): 13 13 13 Test Duration (TF — Ti): 1 hour 1 hour 1 hour 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 TECHNICIAN 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:_ �r��Date:-5-19-09_ ' State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more strineent.