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'R¢g <br /> 0 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 (f 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 Te 4!%3r2,7-!,,7-- <br /> Facility <br /> rd-1,7-Facility Address: 1301 KETTLEMAN LN.LODI,CA 95242 ` <br /> Facility Contact: RUPI Phone: <br /> Date Local Agency Was Notified of Testing:2-24-17 A P 0 10 201? <br /> Name of Local Agency Inspector(fpresent during testing): AARON <br /> 2. TESTING CONTRACTOR INFORMATION ENVIRONMENTAL HEALTH <br /> I NT <br /> Company Name: AFFORDA TEST 416 2nd Street Galt,CA 95632 (209)744-01 Tax4'(209)744-0116 <br /> Technician Conducting Test: ❑ Ed Stearns ❑ Zane A.Nimmo ® David A.Winkler ❑ Felix G.Ramirez <br /> 8184188 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 /> MT 777U7MMM 44 <br /> Identify Spill Bucket(By Tank 1 87 2 3 91 4 DIESEL <br /> " Number, Stored Product, etc.) <br /> ®Direct Bury ❑ Direct Bury ®Direct Bury ®Direct Bury <br /> Bucket Installation Type: E]Contained in El Contained in <br /> El Contained in Sump El Contained in Sump Sump Sum <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(Tj): 1 1 1 <br /> Initial Reading(RI): 14 13 14 <br /> Test End Time(TF): 2 2 2 <br /> Final Reading(RF): 14 13 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 ❑Fail ❑ Pass ❑Fail (D Pass ❑Fail ® Pass ❑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 /> Technician's Signature Date: 3-27-17 <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 />