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Spill Bucket Testing Report Form SWRCB, January 2006 <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. FACILI'T'Y ,INFORMATION <br />Facility Name: CITY OF LODI'------ -- <br />Facility Address: 1331 S HAM LANE LODI CA 95240 Date of Testing: 9.22-1 5 <br />Facility Contact: RANDY <br />Phone: 209-333-6830 <br />Date Local Agency Was Notified of Testing :8-24-15 <br />Name of Local Agency Inspector (tfpresent during testinZ: ARTS <br />— -- -- 2. TESTING CONTRACTOR INFO_R_M_ _ATION <br />Company Name: AFFORDA TEST 416 2nd Street Galt, CA 95632 <br />(209)744-0112 Fax: (209) 744-0116 <br />Technician Conducting Test: ❑ Lyle D. Nimmo ❑ Zane A. Nimmo ® David A. Winkler ❑ Felix G. Ram irez <br />5249115 -UT 5263322 -UT 5263373 -UT 5273934 -UT <br />Credentials: ® ICC Service Tech. ® SWRCB Tank Tester <br />h •, L�� �..,a 1i.131 lrvtz iI'4ykJ 1VdAlION <br />Test Method Used. N Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: TAPE / 1_I20 Equipment Resolution: 1/16 <br />Identify Spill Bucket (Bv Tank 1 87 2 873 DIESEL 4 <br />Number, Slored Product, etc.) <br />Bucket Installation `Type: <br />® Direct Bury <br />❑ Contained in Sump <br />®Direct Bur y <br />❑ Contained in Sump <br />❑ Direct Bury <br />© °ntarned in <br />I2X 15 <br />❑ Direct Bur Y <br />❑ Contained in <br />Sum <br />Bucket Diameter: <br />I 1 <br />1 1 <br />Bucket Depth: <br />14 <br />t <br />24 <br />Wait time between applying <br />vacuum/water and start of test: <br />- <br />Test Start Time (Tr): <br />2 <br />2 <br />Initial Reading (Rr): <br />14 <br />i 2 <br />23 <br />Test End Time (TF): <br />; <br />4 <br />3 <br />Final Reading (RF): <br />14 <br />12 <br />23 <br />Test Duration (TF - Tl): <br />I HOUR <br />I HOUR <br />I HOUR <br />Change in Reading (RF -Rr): <br />Pass/Fail Threshold or <br />Criteria: <br />0 <br />- <br />4 <br />0 <br />- <br />Test Result: <br />Comments _ itn,.t„. 4.;-,r-- <br />® Pass ❑Fail <br />®Pass Ll Fall <br />® Pass ❑ Fail <br />❑ Pass ❑ Fail <br />ALL PASSED <br />- - - - -r -•• •� Y, — «u araeartg, area recommended,Joliow-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: . <br />Date:9-22-15 <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 />