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11 <br />SWRCB, January 2006 <br />Spill Bucket Testing Report Form <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. FACILITY INFORMATION <br />Facility Name: EL DORADO FOOD MART I Date of Testing: 2/13/2018 <br />Facility Address: 2320 N. EL DORADO STREET STOCKTON , CA 95204 <br />Facility Contact: I Phone: <br />Date Local Agency Was Notified of Testing :1/22/2018 <br />Name of Local Agency Inspector (zf present during testing): STACY <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 Stearns ® Zane A. Nimmo ❑ David A. Winkler ❑ Felix G. Ramirez <br />8211269 — 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: ® Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: TAPE MEASURE, H2O <br />Equipment Resolution: 1/16" <br />Identify Spill Bucket (By Tank 1 87 <br />Number, Stored Product, etc. <br />2 <br />3 91 <br />4 DIESEL <br />® Direct Bury <br />Bucket Installation Type: <br />El Contained in Sump <br />❑ Direct Bury <br />F1 Contained in Sump <br />® Direct Bury <br />El Contained in <br />Sump <br />® Direct Bury <br />El Contained in <br />Sum <br />Bucket Diameter: 11 <br />11 <br />I 1 <br />Bucket Depth: 14 <br />13 3/4 <br />12 1/2 <br />Wait time between applying _ <br />vacuum/water and start of test: <br />-- <br />Test Start Time (TI): 0925 <br />0925 <br />0925 <br />Initial Reading (Rj): 13 - <br />12 3/4 <br />11 3/4 <br />Test End Time (TF): 1025 <br />1025 <br />1025 <br />Final Reading (RF): 13 - <br />12 3/4 <br />11 3/4 <br />Test Duration (TF — Ti): HR <br />HR <br />HR <br />Change in Reading (RF - RI): 0 <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />Test Result: 0 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 />MEASURED 5 GALLONS <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 />71 <br />Technician's Signature: Date: 2/13/2018 <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 />