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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 />i FAf iT.TTV INFORMATION <br />Facility Name v GEORGE KISHIDA TRUCKING Date of Testing: 11/18/2016 <br />Facility Address: 1725 ACKERMAN DR City: LODI <br />Facility Contact: KELLI Phone: 209-368-0603 <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (if present during testing): <br />I TFCTTN(_ CnNTRArTOR INFORMATION <br />Company Name: BZ Service Station Maintenance <br />Technician Conducting Test: RHOM E DESBIENS <br />Credentials': CSLB Contractor LCC Service Tech. SWRCB Tank Tester Other (Spec) <br />License Number(s): 433159 <br />'A RPTT.T. R1jVWV.T TF.RTTNG INFORMATION <br />Test Method Used: _ ® Hydrostatic ❑ Vacuum Other <br />Test Equipment Used: RULER Equipment Resolution: 1/16" <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc. <br />1 DSL -1 <br />2 DSL -2 <br />3 4 <br />Bucket Installation Type: <br />Direct Bury <br />❑ Contained in Sump <br />Direct Bury <br />❑ Contained in Sump <br />Direct Bury Direct Bury <br />Contained in Sump Contained in Sum <br />Bucket Diameter: <br />11" <br />11" <br />Bucket Depth: <br />17" <br />18" <br />Wait time between applying <br />vacuum/water and start of test: <br />5 MIN <br />5 MIN <br />Test Start Time (Ti): <br />10:12 <br />11:45 <br />Initial Reading (Rj): <br />15 13/16" <br />16 3/8" <br />Test End Time (TF): <br />11:14 <br />12:45 <br />Final Reading (RF): <br />15 13/16" <br />16 3/8" <br />Test Duration (TF — T,): <br />1 HR <br />I HR <br />Change in Reading (RF —Ri): <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />0 <br />0 <br />Test Result: <br />Pass, ❑ Fail <br />® Pass [3 Fail <br />❑ Pon [) Fail ❑ Pan ❑ Fall <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 port is true, accurate, and in full compliance with legal requirements. <br />i <br />Technician's Signature: •►r"'Date: 11/18/2016 <br />' State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more <br />stringent. <br />Monitoring Certification Test Report <br />4 of 4 <br />