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't"�lanuary 2006 <br />Spill Bucket Testing Report Form <br />This form is intended for use by contractors performing annual testing of UST spill contain s 1 d <br />printouts from tests (if applicable), should be provided to the facility owner/operator for sub alo h�ac r� ,pX agency. <br />1. FACILITY INFORMATION <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: AFFORDA TEST 416 2"d Street Galt, CA 95632 (209) 744-0112 Fax: (209) 744-0116 <br />Technician Conducting Test: ❑Ed Sterns ❑ Zane A. Nimmo ❑ David A. Winkler ® Felix G. Ramirez <br />814188 -UT 8211269 -UT 5263373 -UT 5273934 -UT <br />Credentials': ❑ ICC Service Tech. ❑ SWRCB Tank Tester <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: <br />Facility Name: ESCALON MINI MART Date of Testing: 12-13-17 <br />❑ Vacuum <br />Facility Address: 1097 YOSEMITE AVE ESCALON CA <br />Facility Contact: I Phone: 209-838-1546 <br />Date Local Agency Was Notified of Testing :11-22-17 <br />Name of Local Agency Inspector (if present during testing): SAN JAOQUIN CO <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: AFFORDA TEST 416 2"d Street Galt, CA 95632 (209) 744-0112 Fax: (209) 744-0116 <br />Technician Conducting Test: ❑Ed Sterns ❑ Zane A. Nimmo ❑ David A. Winkler ® Felix G. Ramirez <br />814188 -UT 8211269 -UT 5263373 -UT 5273934 -UT <br />Credentials': ❑ ICC Service Tech. ❑ SWRCB Tank Tester <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: <br />® Hydrostatic <br />❑ Vacuum <br />❑ Other <br />Test Equipment Used: TAPE / H2O <br />Equipment Resolution: <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc. <br />1 87 <br />2 91 <br />3 <br />4 <br />Bucket Installation Type: <br />® Direct Bury <br />❑Contained in Sump <br />® Direct Bury <br />❑Contained in Sump <br />❑ Direct Bury <br />El Contained in <br />Sump <br />❑ Direct Bury <br />❑ Contained in <br />Sum <br />Bucket Diameter: <br />11 <br />11 <br />Bucket Depth: <br />13 <br />13 <br />Wait time between applying <br />vacuum/water and start of test: <br />_ <br />Test Start Time (Ti): <br />945 <br />945 <br />Initial Reading (R,): <br />12 <br />12 <br />Test End Time (TF): <br />1045 <br />1045 <br />Final Reading (RF): <br />12 <br />12 <br />Test Duration (TF — Ti): <br />1 HOUR <br />1 HOUR <br />Change in Reading (RF - RI): <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />Test Result. <br />® Pass ❑ Fail <br />® Pass ❑ Fail <br />® 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 <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:12-13-17 <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 />