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130312-737 <br /> 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/operatorfor submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Lodi CA FO Term (Intl) Date of Testing:411012013 <br /> Facility Address: 2500 West Turner Road <br /> Facility Contact: Dennis Gritsko Phone: (916)373-4626 <br /> Date Local Agency Was Notified of Testing: 411!2013 <br /> Name of Local Agency Inspector(ifpreseni during testing):Aris Caca it <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: SunWest Engineering Inc. <br /> Technician Conducting Test:Todd Hansen <br /> Credentials : CSLB Contractor XN ICC Service Tech.X❑ SWRCB Tank Tester[] Other(Specify) <br /> License Number(s): 703190 8045710 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: Standard Lake Test <br /> Test Equipment Used:Water and measurement reference <br /> Identify Spill Bucket(by Tank Diesel <br /> Number,Stored Product etc. <br /> Bucket Installation Type: Direct Bury irect Bury irect Bury irect Bury <br /> ntained in qnmn 731contained in Sump ntained in Sump ontained in Sum <br /> Bucket Diameter: 12" <br /> Bucket Depth: 14" <br /> Wait time between applying 15 minutes <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 9:30am <br /> Initial Reading(Rr): .5" below grade <br /> Test End Time(TF): 10:30am <br /> Final Reading(R F): .5" below grade <br /> Test Duration(TF-Tt): 60 minutes <br /> Change in Reading(R F-Rj): 0" <br /> Pass/Fail Threshold or 01. <br /> Criteria: <br /> Test Results Pass <br /> Comments- (include in ormation on repairs made prior to testing, and recommended ollow-u or ailed tests <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> 1 hereby certify that all the information contained in this report is true,accurate,and in full compliance with legal requirements. <br /> Dglfally sped by Todd Hansen for WT#130312-737 <br /> Technician's Signature: 041101241311;38,32 Date: 4!1012013 <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 />