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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(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1.FACILITY INFORMATION <br /> =CY <br /> : PLAZA OASIS <br /> Date of Testing: 03-25-14 <br /> ss: 800 S CHEROKEE LANE LODI CA 95240ct: RAMALPhone: 209-368-0127 <br /> gency Was Notified of Testing:02-24-14SAN JOAQUIN CO ARIS <br /> al 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 Conducting Test: [—]Lyle D.Nimmo ❑ Zane A.Nimmo ❑ David A.Winkler ® Felix G.Ramirez <br /> 5249115-UT 5263322-UT 5263373-UT 5273934-UT <br /> Credentialsl: ®ICC Service Tech. ® SWRCB Tank Tester <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> t <br /> d <br /> H rosatic ❑Vacuum El Other <br /> Test Method Used: 20 y Equipment Resolution: 1/16 <br /> Test Equipment Used: TAPE/H2O <br /> Identify Spill Bucket (By Tank 1 87 <br /> 2 91 3 DIE 4 <br /> Number,Stored Product, etc. <br /> Direct Bury E]Direct Bury <br /> ®Direct Bury ®Direct Bury ❑Contained in ❑Contained in <br /> Bucket Installation Type: ❑Contained in Sump ❑Contained in Sump Sum Sum <br /> Bucket Diameter: <br /> 11 11 11 <br /> Bucket Depth: <br /> 13 13 12 <br /> Wait time between applying <br /> vacuum/water and start of test: 900 <br /> Test Start Time(Ti): 900 900 <br /> 12 11 <br /> Initial Reading(R): 12 1000 <br /> Test End Time(TF): 1000 1000 <br /> 12 12 11 <br /> Final Reading(RF): 1 HOUR <br /> Test Duration(TF—Tj): I HOUR 1 HOUR <br /> /p 0 0 <br /> Change in Reading(RF-R): 0 <br /> Pass/Fail Threshold or _ <br /> Criteria: <br /> Test Result: <br /> 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 /> OP BUCKETS nrnC��ECE v�Cn <br /> � <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTG�GLmq�-� <br /> I hereby certify that all the information contained in this report is true,accurate,and in full com <br /> DEPARTMENT <br /> Technician's Signature: <br /> Date:03-25-14 <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 />