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0 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 /> Facility Name: PLAZA OASIS I Date of Testing: 3-23-15 <br /> Facility Address: 800 S CHEROKEE LANE LODI CA 95240 <br /> Facility Contact: Ashok I Phone: 209-368-0127 Vff <br /> Date Local Agency Was Notified of Testing:2-26-15 <br /> Name of Local Agency Inspector('(present during testing): SAN JOAQUIN CO ARIS <br /> 2. TESTING CONTRACTOR INFORMATION ENVIRONMENTA <br /> Company Name: AFFORDA TEST 4162 nd Street Galt,CA 95632 (209)744-0112 Fax(209}TMTM <br /> Technician Conducting Test: ❑ Lyle D.Nimmo ❑ Zane A.Nimmo E David A.Winkler ❑ Felix G.Ramirez <br /> 5249115-UT 5263322-UT 5263373-UT 5273934-UT <br /> Credentials: E ICC Service Tech. ® SWRCB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ®Hydrostatic ❑Vacuum ❑ Other <br /> Test Equipment Used: TAPE/H2O Equipment Resolution: 1/16 <br /> Identify Spill Bucket(By Tank 1 87 2 91 3 DIE 4 <br /> Number, Stored Product, etc. <br /> ®Direct Bury ®Direct Bury <br /> ® Direct Bury Direct Bury <br /> Bucket Installation Type: ElContained in ❑ Contained in <br /> ❑ Contained in Sump ❑Contained in Sump Sum Sum <br /> Bucket Diameter: 11 I1 11 <br /> Bucket Depth: 13 13 12 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(TO: 900 900 900 <br /> Initial Reading(Ri): 12 12.50 11 <br /> Test End Time(TF): 1000 1000 1000 <br /> Final Reading(RF): 12 12.50 11 <br /> Test Duration(TF—Tj): 1 HOUR I HOUR 1 HOUR <br /> Change in Reading(RF-Rj): 0 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: ® Pass ❑ Fail ® Pass ❑ Fail I ® Pass ❑ Fail ❑ Pass ❑ Fail <br /> Comments-(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> OPW BUCKETS <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 /> Te hnician's Signature: Date:3-23-15 <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 />