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Spill Bucket Testing Report Form RE, nye RVEL <br /> This Msessror <br /> prinahomtt (leppll�b9:Tbnn <br /> hfaatyowepkoftoe should er submittal tMa bauaiyep rertcy'l."" 2 2 2016 <br /> f. FACILITY INFORMATION <br /> Facility Name: Rancho San Miguel I Date arresting:1D/25 ME HEALTH <br /> T <br /> Facility Address: 610 S. Cherokee Ln. Lodi, CA 95240- DEPARTME <br /> Facility Contact: Jesus Jurado (209)339-8200 <br /> Date Local Agency Was Notified of Testing: 1017/16 <br /> Name of Local Agency Inspector (irpresent during testing): Fatinah Zareef <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name:Service Station Systems <br /> Technician Conducting Test: Randy Wilkerson <br /> Credentialsi: ❑x CSLB Contractor ❑X ICC Service Tech. ❑SWRCB Tank Tester ❑ Other(Specify) <br /> License Number(s): License:485184 ICC:5258560-UT <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ®Hydrostatic ❑Vacuum ❑ Other <br /> Test Equipment Used: Measuring Tape Equipment Resolution:1/16 In. <br /> Identify Spin Bucket (By Tank 1 Fill Bucket 2 Fill Bucket 3 4 <br /> Number,Stored Product,etc.) 01 -Re u 02-Prem <br /> Bucket Installation Type: ❑ Direct Bury ❑ Direct Bury ❑ Direct Bury ❑ Direct Bury <br /> X❑Contained in Sump ❑X Contained in Sump ❑ Contained in Sump ❑ Contained in Sump <br /> Bucket Diameter: 13.00 in. 13.00 in. <br /> Bucket Depth: 14.00 in. 14.00 in. <br /> Wait time between applying <br /> vacuum/water and start of test: 5 min. $ min. <br /> Test start Time IT, ): 9 30a 9:30am <br /> Initial Reading(R, ): 12.750 in. 12.750 in. <br /> Test End Time(TF): 10:30am 10:30am <br /> Final Reading Tf): 12.750 in. 12.750 in. <br /> Test Duration(TF-T 1): 1.00 hr. 1,00 hr. <br /> Change in Reading(RF -RI): 0.0000 in. 0.0000 In. <br /> Pass/Fall Threshold or Criteria: ZERO LOSS ZERO LOSS <br /> Test Result: IN Pass ❑ Fail ❑X Pass ❑ Fail ❑ Pass ❑Fail ❑ 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 /> 1 hereby certify that all the inforipation contained In this report is true,accurate,and In lull compliance with legal requirements. <br /> Technician's Signature: UI Y _ Date: 10/25/16 <br /> t 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 />