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SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intendedfor use by contractors performing annual testing of UST spill containment structures. The completed form and <br /> printouts from tests(f applicable)should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: VALLEY PACIFIC CARDLOCK#152 Date of Testing: JUNE 29,2006 <br /> Facility Address: 930 E.VICTOR RD., LODI, CA 95240 <br /> Facility Contact: MIKE ELIASON Phone: (209)948-9412 <br /> Date Local Agency Was Notified of Testing: JUNE 16, 2006 <br /> Name of Local Agency Inspector(ifpresent during testing): WILL NG <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANK-TEK ENVIRONMENTAL CORPORATION <br /> Technician Conducting Test: ROB NEIMEYER <br /> Credentials: ®CSLB Contractor ❑ ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other(Spec) <br /> License Number(s): 803705 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ®Hydrostatic ❑Vacuum ❑ Other(Spec) <br /> Test Equipment Used: Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1 2 3 4 <br /> Number, Stored Product, etc.) REGULAR SUPER <br /> Bucket Installation Type: 0 Direct Bury ® Direct Bury F-1DirectBury ❑Direct Bury <br /> ❑Contained in Sump ❑ Contained in Sump ❑ Contained in Sump ❑Contained in Sump <br /> Bucket Diameter: 10.50" 10.50" <br /> Bucket Depth: 11.00" 11.00" <br /> Wait time between applying 0 0 <br /> vacuum/water and start of test: <br /> Test Start Time(TO: 11:00 AM 11:00 AM <br /> Initial Reading(RO: 11.00" 11.00" <br /> Test End Time(TF): 11:30 AM 11:30 AM <br /> Final Reading(RF): 11.00" 11.00" <br /> Test Duration(TF—TJ: 30 MIN 30 MIN <br /> Change in Reading(RF-R,): 0 0 <br /> Pass/Fail Threshold or Criteria: <br /> Test Result: ®Pass ❑Fail 1 ® Pass ❑Fail ❑ Pass []Fail ❑ Pass ❑Fail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up for failed tests) <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: JUNE 29,2006 <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 />