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P6ECEIVED <br />NOV 16 2017 <br />SWRCB, January 2006 <br />Spill Bucket Testing Report FoBOVIRONMENTAL HEALTH <br />This form is intended for use by contractors performing annual testing of UST spill containment sREPuARTME4T1e1edjbrm and <br />printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION Facilitv ID: 01 <br />Facility Name: Unified Grocers, Inc Date of Testing: 11/08/2017 <br />Facility Address: 1990 Piccoli Rd. Stockton CA 95215 <br />Facility Contact: Todd George Phone: 209-931-7431 <br />Date Local Agency Was Notified of Testing: 11-6-2017 <br />Name of Local Agency Inspector (f present during testing): Elianna Florido <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: TAIT Environmental Services <br />Technician Conducting Test: Garrett Warren <br />Credentials': ❑x CSLB Contractor ❑x ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other (Specify) <br />License Number(s): A B ASB C-10 HAZ, 588098 ICC 8185019 <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: ZX Hydrostatic ❑Vacuum ❑Other <br />Test Equipment Used: Tape Measure <br />Equipment Resolution: 1/16" <br />a .... - <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc) <br />1 T1 Diesel <br />2 <br />3 <br />4 <br />Bucket Installation Type: <br />❑x Direct Bury <br />❑Contained in Sump <br />❑On Top of AST <br />[I Direct Bury <br />❑Contained in Sump <br />0 O Top of AST <br />[]Direct Bury <br />❑Contained in Sump <br />[]On Top of AST <br />❑Direct Bury <br />❑Contained in Sump <br />[]On Topof AST <br />Bucket Diameter: <br />11" <br />Bucket Depth: <br />13.50" <br />Wait time between applying <br />vacuum/water and start of test: <br />15 min. <br />Test Start Time (Ti): <br />10:49 am <br />Initial Reading (RI): <br />12.50" <br />Test End Time (TF): <br />11:49 am <br />Final Reading (RF): <br />12.50" <br />Test Duration (TF — TI): <br />1 hour <br />Change in Reading (RF - RI): <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />0 <br />Test Result: <br />❑x 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 />Test water was left on site. <br />1 hr test approved per Elianna Florido. Inspector. <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: 06m " 70"wo <br />Date: 11/08/2017 <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 />