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i.L <br /> M A iR 0 <br /> Spill Bucket Testing Report Form 9 ;TYTCB,January 2006 <br /> This form is intended for use by contractors performing annual testing of UST spill conta)n: 'Akt)MV <br /> , ted form and <br /> printouts from tests(ifapplicable), should be provided to the facility ownerloperatorfor submi-Ifidt7b,tw1ocat-regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: FLAME LIQUORS Date of Testing: 3-3-2015 <br /> Facility Address: 1301 KETTLEMAN LN. LODI, CA 95242 <br /> Facility Contact: RUPI Phone: 334-3233 <br /> Date Local Agency Was Notified of Testing:2-23-15 <br /> Name of Local Agency Inspector(present during testing): Aris Veloso <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2 d Street Galt,CA 95632 (209)744-0112 Fax:(209)744-0116 <br /> Technician Conducting Test: El Zane A.Nimmo 0 David A.Winkler El Felix G.Ramirez <br /> 5263322-UT 5263373-UT 5273934-UT <br /> Credentials: 0 ICC Service Tech. SWRCB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: Z Hydrostatic El Vacuum El Other <br /> Test Equipment Used: TAPE MEASURE, H2O Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By Tank 1 87 2 3 91 4 DIESEL <br /> Number, Stored Product, etc. <br /> Z Direct Bury El Direct Bury -0 Direct Bury Direct Bury <br /> Bucket Installation Type: E]Contained in Sump El Contained in Sump r-1 contained in E]Contained in <br /> Sump Sump <br /> Bucket Diameter: 11 11 11 <br /> Bucket Depth: 14 1/4 14 1/2 15 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 1130 1130 1130 <br /> Initial Reading(Ri): 13 1/4 13 1/2 14 <br /> Test End Time(TF): 1230 1230 1230 <br /> Final Reading(RF): 13 1/4 13 1/2 14 <br /> Test Duration(TF—Ti): HR HR HR HR <br /> Change in Reading(RF-Rj): 0 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: Z Pass El Fail 0 Pass El Fail 0 Pass El Fail Z Pass El Fail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> ®PW FLAPPERS <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 /> T ghnician's Signature Date: 3-3-2015 <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 />