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R6CF.IVED <br /> r <br /> iK0 42017 <br /> SWRCB,January 2006 <br /> Spill Bucket Testing Report Form IRONMENTTH <br /> This form is intended for use by contractors performing annual testing of UST spill con atnment _ leted form and <br /> printouts from tests(if applicable), should be provided to the facility owner/operator for submittttl'Mdt e'loca regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: FLAME LIQUORS I Date of Testing: 3-27-17 <br /> Facility Address: 1301 KETTLEMAN LN.LODI,CA 95242 <br /> Facility Contact: RUPI Phone: <br /> Date Local Agency Was Notified of Testing:2-24-17 <br /> Name of Local Agency Inspector(f present during testing): AARON <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 4162"d Street Galt,CA 95632 (209)744-0112 Fax:(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 /> "i i.r.�i rrr + ';':'. b JGr<„i, ,. ::; �,-,.,,1✓e:.: ,>,o s—_.r(”. , A. �df H i}i etJ{a i✓,.,. •;,. :.�:1'Z l _ s i fes..:: <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: El Contained in <br /> El Contained in Sump E]Contained in Sump El Contained in <br /> 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(Ti): 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: Z Pass [:]Fail ❑_Pass ❑Fail 0 Pass ❑Fail Z Pass ❑Fail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> _OPW 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 W 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 />