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y <br /> 14Q224-4 <br /> SWRCB,January 2005 <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:Lodi CA FO Terni(Intl) Date of Testing:4/9/2014 <br /> Facility Address:2500 West Turner Road <br /> Facility Contact: Dennis Gritsko Phone, (916)205-9291 <br /> Date Local Agency Was Notified of Testing:4'112014 <br /> Name of Local Agency Inspector ff resent during testing).Aris Cacapit <br /> 2. TESTING CONTRACTOR INFORMATION <br /> any Name: SunWest Engineering Ince <br /> nician Conducting Test:Todd Hansen <br /> [C;r;.:dntials : CSLB Contractor d ICC Service Tech-[A SWRCB Tank Tester Other(Specify) <br /> License is <br /> 703190 8045710 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: Hydrostatic <br /> Test Equipment Used:Ineon TS-STS and Ovate: <br /> Identify Spill.Bucket(by Tank Diesel <br /> Number Stored Product etc. <br /> Bucket Installation'Type: Direct Bury Direct Bury LiArect Buryirect Bury <br /> stained in Surnp Contained in Sunip UContained in Sum UlContained 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): 9:08am/9.24am <br /> Initial Reading(Ri): 2.4503"/2,4503" <br /> Test End Time(TF): 9:23arn!9:39am <br /> Final Reading(RF): 2,4501"12.4499" <br /> Test Duration(TF-Tt): 2 x 15 minutes <br /> Change in Reading(RF-R[): .0002"/.0004" <br /> Pass/Fail Threshold or i002" <br /> Critcri:�: <br /> Test Results Pass <br /> Comments-(include information on repairs madeprior iv testing, and recommended Ilow-upfor uilc d tcstsr <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 colnplianre with legal requir¢ments <br /> D�itally signed by Todd Hansen for WT#146224441 <br /> Technician's Signature: UN/11410:56:48 Date: 4/9/2014 <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 />