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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/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: CHEROKEE LANES SVC ARCO Date of Testing: 10-27-10 <br /> Facility Address: 900 S CHEROKEE LANE LODI CA _ <br /> Facility Contact: DARJEET Phone: <br /> Date Local Agency Was Notified of Testing: -- <br /> Name of Local Agency Inspector (if present during testing): 11 <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 4162 nd Street Galt, CA 95632 (209)744-0112 Fax: (209)744-0116 <br /> Technician Conducting Test: ❑ Lyle D.Nimmo ❑ Zane A.Nimmo 0 David A. Winkler ❑ Felix G. Ramirez <br /> 5249115-UT 5263322-UT 5263373-UT 5273934-UT <br /> Credentials: ® ICC Service Tech. ® SWRCB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION _ <br /> Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br /> Test Equipment Used: h20 and tape measure Equipment Resolution: 1/16 JI <br /> Identify Spill Bucket (By Tank 1 871 2 872 3 91 4 DSL <br /> Number, Stored Product, etc. <br /> ® Direct Bury ® Direct Bury ® Direct Bury Z Direct Bury <br /> Bucket Installation Type: ❑ Contained in El in <br /> ❑ Contained in Sump El Contained in Sump Sum Sum <br /> Bucket Diameter: 11 I 1 11 11 <br /> Bucket Depth: 12 14 15 10 <br /> Wait time between applying _- -- <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 2 2 2 2 <br /> Initial Reading(Rj): 11 13 14 9.50 <br /> Test End Time(TF): 3 3 3 3 <br /> Final Reading(RF): 11 13 14 9.50 <br /> Test Duration(TF—Tj): IHR IHR IHR IHR <br /> Change in Reading(RF-Rj): 0 0 0 O <br /> Pass/Fail Threshold or 1/16 1/16 1/16 1/16 <br /> Criteria: <br /> Test Result: ® Pass ❑ Fail ® 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: V116—i Date 10-27-10 <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 />