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NOV 202014 <br /> EWRONA"- <br /> Spill Bucket Testing Report Form t)&-,-; T,YIEINT <br /> TArs form is imendedfor we by eontraett rs imforming annual testing of UST sp111 containment slruetures. The completed form and <br /> printouts from tests(tf applicable),shout I be provided to the facibry owner1cperworfor svbminal to the local regulatory agency. <br /> I. <br /> FACQdTY INFORMATION <br /> Facility Name: Wine Country;'6 Daze of Testing: 10/2212014 <br /> Facility Address: 1 I l l E.Kettlemen Lo.,Lodi,CA 95240 <br /> PatnhtyContacr. Soanie I Phonc: (408)806-9148 <br /> Date Local Agency Was Notified of Tesw g: /0—0 2-1 <br /> Name of Local Agency Inspector refpresetu during telling) Michelle Henry <br /> 2. TEST fNG CONTRACTOR INFORMATION <br /> Company Name: Reliabic Petro.eum Services Inc. <br /> Technician Conducting Test: Guadalupe Sanchez <br /> Credentials': x CSLB Contractor x ICC Service Tech. 0 S W RCD Tank Tester 0 Other(S ec fry) <br /> Lirx,nse Number(s)' 883706 5250451-UT <br /> 3. SPILL BUCKET TESTING MORKATION <br /> TntMUhodUsed: xHydrossatic 0Vacuum 00t1w <br /> Tat Equipment Used: Standard Tape Met sure Equipment Resalufion: <br /> .....e.,....._ _z.....,.,.. . <br /> identify Spill Bucket(By Tann 1 Tl:87 Fill 2 T2:91 Fill 3 T3:Diesel Fill .4 _ <br /> Amber,—Stared product,etc <br /> Bucket Installation Type: x Direc Bury x Direct Bury x Direct Bury xDirect Bury <br /> fl Contal ted in Sum ❑Contained in Sum n Contained in Su ❑Contained in S <br /> urnp <br /> Bucket Diameter: 12" 12" 12" <br /> Bucket Depth: 14" 14 t,/." <br /> 13'A" <br /> Wait time between applying <br /> vacuum/water and start of test 1 min. I min 1 min. <br /> Test Start Time My 5:30 a.m. 930 s m. 9:30 a.m. <br /> InitialReading()kj: 12718" L31/8" 11W <br /> Test Pad Time(Ty): 10;3 m. I0:30a.m. 10:30 am. <br /> Final heading(Re): 12 7l8" 11 118" 11 <br /> Teel Dutation(TF—TJ: I hr lhr 1 hr <br /> Cltattge in Reading(Rr-RAI ( 0 0 <br /> PasalFai1.11Mold or 1118' <br /> Criteria: 1/16" 1/16" <br /> Test RC6ult: Y Pas ❑Fail _ x Pass D Fail x Pass 0 Fail Pu03 ail <br /> Commen ts—(include in ormatton on rt pairs made prior to tesitV. and recommended follow-up for failed tests) <br /> CERTIFICATION OFTE,--HNICIAN RESPONSMLE FOR CONDUCTING TATS TESTING <br /> I hereby certify that all the information c onlained in this report 16 true,dcearetg4 and in faH compliance with legal regefreuren&. <br /> 't'echnician's Signature: <br /> Date 10/22/2014 <br /> 'State lawsand regulations do not currently require testing to be performed by a quCified contractor.however,local requirements <br /> may be more stringent. <br /> Z i'd £968948602 =61011ed B1ge11ey eL£:40 YL 0Z AoN <br />