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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 /> printoutsfrom tests(if applicable),should be provided to the facility owner/operatorfor 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 <br /> Date Local Agency Was Notified of Testing:2-26-15 <br /> Name of Local Agency Inspector(ifpresent during testing): SAN JOAQUIN CO ARIS <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2nd Street Galt,CA 95632 (209)744-0112 Fax:(209)744-0116 <br /> Technician Conducting Test: ❑Lyle D.Nimmo ❑ Zane A.Nimmo M David A.Winkler ❑ Felix G.Ramirez <br /> 5249115-UT 5263322-UT 5263373-UT 5273934-UT <br /> Credentials: M ICC Service Tech. M SWRCB Tank Tester <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ®Hydrostatic ❑Vacuum ❑ Other <br /> Test Equipment Used: TAPE/H20 EquipmentResOlutiun: 1/16 <br /> Identify Spill Bucket(By Tank 1 87 2 91 3 DIE 4 <br /> Number, Stared Product, etc. <br /> ® Direct Bury M Direct Bury Direct Bury El Direct Bury <br /> Bucket Installation Type: ❑Contained in ❑Contained in <br /> ❑ Contained in Sump ❑ Contained in Sump SumpSum <br /> Bucket Diameter: 1 I 11 11 <br /> Bucket Depth: 13 13 12 <br /> Wait time between applying <br /> vacuum/water and start of test: m. _ <br /> Test Start Time(Tu): 900 900 900 r <br /> Initial Reading(Ru): 12 12.50 11 <br /> Test End Time(TP): 1000 1000 1000 APR <br /> Final Reading(Rr): 12 12.50 11 <br /> Test Duration(Tr—Tu): 1 HOUR 1 HOUR 1 HOUR <br /> Change in Reading(RF-R): 0 0 0 _7 L54LTH '.,'tir.. <br /> Pass/Fail Threshold or <br /> Criteria: <br /> `.Test Result: M Pass ❑ Fail M Pass ❑Fail M Pass ❑ Fail I ❑ Pass ❑ Fail <br /> Comments— (include information on repairs made prior to testing, and recommendedfollow-upforfailed 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 />