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RECEIVED <br /> SWRCB,January 2006 <br /> Spill Bucket Testing Report Form MAY 18 20t8 <br /> This form is intended for use by contractors performing annual testing of UST spill contammeo ET 01�mpleted form and <br /> printouts from tests(if applicable), should be provided to the facility owner/operator for submtory agency. <br /> 1.FACILITY INFORMATION HEAL <br /> Facility Name: PLAZA LIQUORS#1 Date of Testing: 03-30-18 <br /> Facility Address: 800 S CHEROKEE LANE LODI,CA 95242 <br /> Facility Contact: RAJ I Phone: 209-368-0127 <br /> Date Local Agency Was Notified of Testing:02-28-18 <br /> Name of Local Agency Inspector(fpresent during testing): SAN JOAQUIN CO CEASER <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: ❑ 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 /> 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, S[ored Product, etc. <br /> Bucket Installation Type: <br /> ®Direct Bury ® Direct Bury ® Direct Bury ❑ Direct Bury❑ Contained in Sump ❑ F1 Contained in [I Contained inContained in Sump Sump Sum <br /> Bucket Diameter: 11 11 I I <br /> Bucket Depth: 13 13 12 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Tj): 1230 1230 1230 <br /> Initial Reading(Ri): 12 12 11 <br /> Test End Time(TF): 1330 1330 1330 <br /> Final Reading(RF): 12 12 11 <br /> Test Duration(TF—Tj): 1 HOUR 1 HOUR 1 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 /> OPW BUCKETS GAS <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: Date:03-30-18 <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 />