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*ill 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(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:11/25/2013 <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: 2013-11-19 <br /> Name of Local Agency Inspector(ifpresent during testing): <br /> TESTIN G CONTRACTOR INFORMATION <br /> Company Name: TAIT Environmental Services,Inc. <br /> Technician Conducting Test: Victor Guerrero <br /> Credential t : F CSLB Contractor F ICC Service Tech. SWRCB Tank Tester F Other(Specify) Incon TS-STS <br /> License number(s):A B ASB C-10 HAZ License Number 588098 : 8017001-UT;3581763704 <br /> SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: F Hydrostatic Vacuum r— Other <br /> Test Equipment Used: Incon TS-STS Equipment Resolution: .0006 <br /> Identify Spill Bucket(By Tank 1 T1:DSL <br /> Number,Stored Product,etc. <br /> Bucket Installation Type: F Direct Bury Direct Bury Direct Bury Direct Bury <br /> Contained in Sump r— 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: 14" <br /> Wait time between applying 15 min. <br /> vacuum/water and start of test: <br /> Test Start Time(Tj): 9:26 am/9:47 am <br /> Initial Reading(Rj): 3.3512/3.3507 <br /> Test End Time(TF): 9:41 am/ 10:02am <br /> Final Reading(RF): 3.3509/3.3508 <br /> Test Duration(TF—Tj): 15 min./15 min. <br /> Change in Reading(RF-Rj): .0003/.0001 <br /> Pass/Fail Threshold or .002/.002 <br /> Criteria: <br /> Test Result: F Pass � Fail Pass Fail Pass Fail 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 on-site in wastetank <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: f Date: 11/25/2013 <br />