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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: Stop N Shop I Date of Testing: 6/16/17 <br />Facility Address: 1856 COUNTRY CLUB BLVD STOCKTON , CA 95204 <br />Facility Contact: Sonny Phone: <br />Date Local Agency Was Notified of Testing :6/9/17 <br />Name of Local Agency Inspector (f present during testing): <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: ®Ed Stearns ❑ Zane A. Nimmo ❑ David A. Winkler ❑ Felix G. Ramirez <br />5250492 -UT 5263322 -UT 5263373 -UT 5273934 -UT <br />i Credentials': ® ICC Service Tech. ® SWRCB Tank Tester II <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: TAPE MEASURE <br />Equipment Resolution: 1/16 <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc. <br />1 87 <br />2 91 <br />3 <br />4 <br />Bucket Installation Type: <br />® Direct Bury <br />❑Contained in Sump <br />® Direct Bury <br />❑ Contained in Sump <br />❑ Direct Bury <br />❑ Contained in <br />SumpSum <br />❑ Direct Bury <br />❑ Contained in <br />Bucket Diameter: <br />11 <br />11 <br />Bucket Depth: <br />13 <br />13 <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (Ti): <br />130 <br />130 <br />Initial Reading (Rj): <br />12 <br />12 <br />Test End Time (TF): <br />230 <br />230 <br />Final Reading (RF): <br />12 <br />12 <br />Test Duration (TF — TI): <br />1HR <br />IHR <br />Change in Reading (RF - RI): <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />1/16 <br />1/16 <br />1/16 <br />Test Result: <br />® 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 />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: � Datc:6-16-17 <br />1 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 />