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p ms <br /> SWRCB.Januar% 2006 <br /> Spill <br /> lll Bucket Testing FO1NV ONMETAL <br /> nogju ,rray07RAPN <br /> T <br /> r1hicJc»nis intended1lr use ht cnntrac `performing rrirlsll <br /> aatures. 7lre(c urplcrc a t«r rrr rrrrel <br /> printouts ji•orn tests ({I'upplicahle), should he provided to the,fiwilitY owner,%operator fin-submitral to the local rcguhv,,r r r,,%it lt:i. <br /> 1. FACILITY INFORMATION <br /> Facility Name: H& M KWIK SERVE BW98 Date of Testin": ----10'6/20!7 �- <br /> ----- - __4 <br /> Facility Address: 2501 E. JACKSON <br /> Facility Contact: MODESTO Phone: 209-838-3971 1. <br /> Date focal Agency Was Notified of Testing <br /> Name of Local Agency Inspector('ij'present dnrinlr testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name L.C.SERVICES -- � - <br /> Technician Conducting- test: Pf-ti-t< W EN'l BROOK <br /> I CSLB Contractor X ICC Service"Lech. SWRCB Tank Tester A Other(Sj�ecrJty <br /> License Ntrmhe -- f <br /> Credentials <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: X-- Hydrostatic Vacuum Other I <br /> Test Equipment.Used: WATER Equipment Resolution: 'TAP <br /> , n <br /> - — <br /> Identify Spill <br /> JU1N�:1 L ,TUih DSL Fe <br /> ( J 4 9 <br /> Number, .Stored Product, etc.) <br /> Buckct Installation Type: X Direct Bury Direct Bury Direct Bury Duca RUP, <br /> Contained in Surnp _ Contained in Sump Contained in Sump C ontaincd in Sulnm <br /> Bucket Diameter: 12" <br /> Bucket Depth: 14" <br /> --- -_-- -------- <br /> Wait time between applying <br /> 30-MIN <br /> vacuum/water and start of test: <br /> Test Start Time(Tr): 1:0013M <br /> Initial Reading(Rr): 14- <br /> Test End Time(Tr): 2:00PM <br /> Final Reading(Rr): 14" � <br /> Test Duration(Tt, T,): I-HR <br /> Change in Reading(Rr-R,): NONE <br /> Pass/Fail Threshold or <br /> Criteria: VA'*S <br /> Test Result: X FassFail Pass Fail Pass Fail P Pass [I Fail 1' <br /> Comments—(include information r»7 repairs muck lrrior to testing, and r econrrncncled>olluH-rrr/lir jailed tests) <br /> RETESTED A ER REPLACING DSL SPILL BUCKET ALT. TE.S_T P-A-S�_�_ <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I herehy certify that all the Information contained in this report is true,accurate,and M full compliance with leg-of requirements, <br /> nts, <br /> Technician's Signature: — Date: E? - "1//7 <br /> State laws and regulations do not currently require testing to be performed by a qualified contractor, However, local requiremenrti <br /> may be more stringent. <br />