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SWRCB, January 2006 <br />Spill Bucket Testing Report Form FLS 2017 <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 (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1 FAf'ii.iTV iNFnRMATInN <br />Facility Name: Country Club Circle K I Date of Testing: 1-23-17 <br />Facility Address: 2575 COUNTRY CLUB BLVD STOCKTON CA 95204 <br />Facility Contact: DAVE HINDS Phone: 209-932-1307 <br />Date Local Agency Was Notified of Testing :12-27-16 <br />Name of Local Agency Inspector (if present during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: AFFORDA TEST 416 2na 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 />I CPTi.T, RIT(`KF.T TF.CTING INFORMATION <br />Test Method Used: <br />® Hydrostatic <br />❑ Vacuum <br />❑ Other <br />Test Equipment Used: TAPE / H2O <br />Equipment Resolution: <br />1/16 <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc. <br />_ <br />1 87 <br />2 91 <br />3 DIE <br />4 <br />Bucket Installation Type: <br />❑ Direct Bury <br />®Contained in Sump <br />El Direct Bury <br />®Contained in Sump <br />Direct Bury <br />El® Contained in <br />Sump <br />E] Direct Bury <br />El Contained in <br />Sum <br />Bucket Diameter: <br />11 <br />11 <br />11 <br />Bucket Depth: <br />13 <br />13 <br />13 <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (Ti): <br />12 <br />12 <br />12 <br />Initial Reading (Rj): <br />13 <br />10 <br />10 <br />Test End Time (TF): <br />1 <br />1 <br />1 <br />Final Reading (RF): <br />13 <br />10 <br />10 <br />Test Duration (TF — TI): <br />I HOUR <br />1 HOUR <br />1 HOUR <br />Change in Reading (RF - Ri): <br />0 <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />-Test Result: <br />Z Pass [:]Fail <br />® Pass El Fail <br />I E Pass ❑ Fail <br />❑ Pass ❑ Fail <br />Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />PHIL TITE BUCKETS. 91 AND DSL BUCKETS NOT 5 GAL. TEST PASSED. <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:01-29-16 <br />' State laws and regulations do not currently require testing to be performed by a qualified contractor. However, <br />local requirements may be more stringent. <br />