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RECEIVED <br /> MAY 21 N%RCB,January 2006 <br /> Spill Bucket Testing Report FormENVIFIONMENTAL <br /> This form is intended for use by contractors performing annual testing of UST spill contair r ) s� rMll RI feted form and <br /> printouts from tests(ifopplicable), should be provided to the facility owner/operator for su mt a to the loca regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: PLAZA LIQUORS#1 1 Date of Testing: 03-30-18 <br /> Facility Address: 800 S CHEROKEE LANE LODI,CA 95242 <br /> Facility Contact: RAJ Phone: 209-368-0127 <br /> Date Local Agency Was Notified of Testing:02-28-18 <br /> Name of Local Agency Inspector(ifpresent during testing): SAN JOAQUIN CO CEASER <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2"a Street Galt,CA 95632 (209)744-0112 Fax: (209)744-0116 <br /> Technician Conducting Test: ❑Ed Steams ❑ 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, Stored Product, etc. <br /> ® Direct Bury E]Direct Bury <br /> Bucket Installation Type: ® Direct Bury ®Direct Bury ❑ Contained in ❑ Contained in <br /> ❑ Contained in Sump ❑Contained in Sump SumpSum <br /> Bucket Diameter: 11 11 11 <br /> Bucket Depth: 13 13 12 <br /> Wait time between applying _ _ - <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 1230 1230 1230 <br /> Initial Reading(R,): 12 12 11 <br /> Test End Time(TF): 1330 1330 1330 <br /> Final Reading(RF): 12 12 11 <br /> Test Duration(TF—T,): 1 HOUR I HOUR 1 HOUR <br /> Change in Reading(RF-R,): 0 0 0 <br /> Pass/Fail Threshold or _ <br /> Criteria: <br /> Test Result: ® Pass F1Fail ® Pass ❑ Fail ® Pass El Fail El Pass El Fail <br /> Comments—(include information on repairs made prior to testing and recommended follow-up for failed tests) <br /> OPW RTT(''TIETS 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 />