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1 I <br /> MAR � 2019 SWRCB , January 2006 <br /> Spill Bucket Testing Report Form n1 Q <br /> This form is intended for use by contractors performing annual testing of UST s�ih o ltaininent' sErltTit74 1 h OTO leted form and <br /> printouts from tests (f applicable), should be provided to the facility owner/operator for jibmittal, logical regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name : GREWAL' S GAS & LIQUOR Date of Testing : 4/5/2018 <br /> Facility Address: 4100 E. FREMONT STREET STOCKTON, CA 95215 <br /> Facility Contact: RICK GREWAL Phone : <br /> Date Local Agency Was Notified of Testing: 3/19/2018 <br /> Name of Local Agency Inspector (if present during testing) : ALIANNA <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 Conducting Test: ❑ Ed Stearns ® Zane A. Nimmo ❑ David A. Winkler ❑ Felix G. Ramirez <br /> 8883080-UT 8883064-UT 8883059-UT 8883072-UT <br /> Credentials ' : ® ICC Service Tech. ® SWRCB Tank Tester <br /> I SPILL BUCKET TESTING INFORMATION <br /> Test Method Used : ® Hydrostatic ❑ Vacuum ❑ Other <br /> Test Equipment Used : TAPE MEASURE, H2O Equipment Resolution: 1 /16 " <br /> Identify Spill Bucket (By Tank 1 87 2 3 91 4 DIESEL <br /> Number, Stored Product, etc. <br /> ® Direct Bury ® Direct Bury <br /> Bucket Installation Type : ® Direct Bury ❑ Direct Bury ❑ Contained in ❑ Contained in <br /> ❑ Contained in Sump ❑ Contained in Sump SumpSum <br /> Bucket Diameter: 11 11 11 <br /> Bucket Depth: 11 12 15 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time (Ti) : 0900 0900 0900 <br /> Initial Reading (RI) : 11 12 14 - <br /> Test End Time (TF) : 1000 1000 1000 <br /> Final Reading (RF) : 11 12 14 - <br /> Test Duration (TF — TI) : HOUR HOUR HOUR <br /> Change in Reading (RF - RI) : 0 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: ® Pass ❑ Fail ❑ Pass ❑ Fail ® Pass ❑ Fail ® Pass ❑ Fail <br /> Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> MEASURED ALL 5 GALLONS <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 : e W Date : 4/5 /2018 <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 />