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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: FLAME LIQUORS Date of Testing: 6/6/12 <br /> Facility Address: 1301 KETTLEMAN LN. LODI, CA 95242 <br /> Facility Contact: RUPI I Phone: <br /> Date Local Agency Was Notified of Testing:6/6/12 <br /> Name of Local Agency Inspector(fpresent during testing): ARIS CACAPIT <br /> 2.TESTING CONTRACTOR INFORMATION t< <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 ❑ 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: TAPE MEASURE, H2O Equipment Resolution: 1/16" <br /> ., I 11,. I,.,.. M2 <br /> Identify Spill Bucket(By Tank 1 87 2 3 91 4 DIESEL <br /> Number, Stored Product, etc.) <br /> ®Direct Bury El Direct Bury <br /> Direct Bury Direct Bury <br /> Bucket Installation Type: ❑Contained in ❑Contained in <br /> ❑Contained in Sump ❑ Contained in Sump Sump Sum <br /> Bucket Diameter: it 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): 0940 0940 0940 <br /> t <br /> al Reading(RI): 13 1/4 13 1/2 14 <br /> End Time(TF): 1040 1040 1040 <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-RI): 0 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: ® Pass ❑Fall ❑ Pass [I Fall 9 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: <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 />