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will Bucket Testing Report Form 0 <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(if applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> FACILITY INFORMATION Facility ID: 01 <br /> Facility Name: Unified Grocers,Inc. Date of Testing:11/18/2014 <br /> Facility Address: 1990 Piccoli Road, Stockton, CA 95215 <br /> Facility Contact: Mike Young Phone: (209)931-7431 <br /> Date Local Agency Was Notified of Testing. 2014-11-11 1 —r. Ell 11-D <br /> Name of Local Agency Inspector(ifpresent during testing): Jeff Wong DEC 12 2014 <br /> TESTING CONTRACTOR INFORMATION w <br /> Company Name: TAIT Environmental Services,Inc. LTH <br /> DEEP , <br /> Technician Conducting Test: Victor Guerrero <br /> Credential 1 : rl- CSLB Contractor P_ ICC Service Tech. I- SWRCB Tank Tester r-Other(Specify) <br /> License number(s): A B ASB C-10 HAZ License Number 588098 : 8017001-UT <br /> SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: F' Hydrostatic Vacuum Other <br /> Test Equipment Used: Tape Measure Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By Tank <br /> Number,Stored Product,etc.) I T1: Diesel <br /> Bucket Installation Type: Direct Bury r Direct Bury r Direct Bury I-Direct Bury <br /> Contained in Sump Contained in Sump Contained in Sump Contained in Sump <br /> On top of AST On top of AST On top of AST On top of AST <br /> Bucket Diameter: 11" <br /> Bucket Depth: 13.5" <br /> Wait time between applying 15 min. <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 9:45 am <br /> Initial Reading(RI): 12.5" <br /> Test End Time(TF): 10:45 am <br /> Final Reading(RF): 12.5" <br /> Test Duration(TF-Tt): 1 hour <br /> Change in Reading(RF-RI): 0 <br /> Pass/Fail Threshold or 0 <br /> Criteria: <br /> Test Result: Pass F Fail r Pass r Fail f- Pass F Fail r- Pass r- Fail <br /> Comments-(include information on repairs made prior to testing, and recommendedfollow-up for failed tests) <br /> All test water was left in site wastewater tank. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I herebycerdfy that all the information contained in this report is true, accurate, and in full compliance with legal requirements. <br /> Technician's Signature: `� Date: 11/18/2014 <br />