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VIECEIVED SW CB J nuary 2006 Spill Bucket Testing Report Form This form is intended for use by contractors performing annual testing of UST spill containmen �rr et printouts from tests (if applicable), should be provided to the facility owner/operator for sub h %Yency!.!W 1. FACILITY INFORMATION Facility ID: 01 ERAS � 2. TESTING CONTRACTOR INFORMATION Company Name: TAIT Environmental Services Technician Conducting Test: Wes Morrison Credentials': ❑x CSLB Contractor ® ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other (Specify) License Number(s): A B ASB C-10 HAZ, 588098 8250125 3. SPILL BUCKET TESTING INFORMATION Test Method Used: ❑x Hydrostatic ❑Vacuum ❑Other Facility Name: Unified Grocers, Inc Date of Testing: 11-21-2016 Equipment Resolution: 1/16" Facility Address: 1990 Piccoli Rd. Stockton CA 95215 Facility Contact: Todd George I Phone: (209) 931-7431 Date Local Agency Was Notified of Testing: 11/11/2016 T1 Diesel Name of Local Agency Inspector (afpresent during testing): Vicky McCartney 2. TESTING CONTRACTOR INFORMATION Company Name: TAIT Environmental Services Technician Conducting Test: Wes Morrison Credentials': ❑x CSLB Contractor ® ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other (Specify) License Number(s): A B ASB C-10 HAZ, 588098 8250125 3. SPILL BUCKET TESTING INFORMATION Test Method Used: ❑x Hydrostatic ❑Vacuum ❑Other Test Equipment Used: Tape Measure Equipment Resolution: 1/16" Identify Spill Bucket (By TankI Number, Stored Product, etc.) T1 Diesel 2 3 4 Bucket Installation Type: ❑x Direct Bury ❑Contained in Sump ❑On Top of AST [I Direct Bury []Contained in Sump El On Top of AST []Direct Bury ❑Contained in Sump ❑On Top of AST ❑Direct Bury ❑Contained in Sump ❑On Topof AST Bucket Diameter: 11" Bucket Depth: 13.5" Wait time between applying vacuum/water and start of test: 15 min Test Start Time (Ti): 9:15am Initial Reading (Ri): 11.25" Test End Time (TF): 10:15am Final Reading (RF): 11.25" Test Duration (TF — TI): 1 hr Change in Reading (RF - Ri): 0 Pass/Fail Threshold or Criteria: 0 Test Result: Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) All test water was left on site. CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING I hereby certify that all the information contained in this report is true, accurate, and in full compliance with legal requirements. Technician's Signature: 11-21-2016 State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more stringent.