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0 0 <br />Spill Bucket Testing Report Form <br />This.form is intended _for use hi� contractors performing annual testing of (IST spill containment stt*ucturey. The complett l fin -in and <br />printouts from tests (if applicable), should he provided to the facility owner/operator, for submittal to the local regulator.) a,�>encr. <br />Facility Name: ARCO AMPM I Date of Testing: 9/28/2015 <br />Facility Address: 880 E VICTOR RD City: LODI <br />Facility Contact: KARAN Phone: 209-369-0958 <br />Date Local Agency Was Notified of Testing: Friday, August 14, 2015 <br />Name of Local Agency Inspector (if present during testing: FATINAH ZAREEF <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: BZ Service Station Maintenance <br />Technician Conducting Test: RHOME DESBIENS HFAITIJ r'=AD-4#CR — <br />Credentials: 0 CSLB Contractor ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other (Specifi•) <br />License Number(s): 433159 <br />3. SPILL BUCKET TESTING INFnRMATInN <br />Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: TAPE MEASURE <br />Equipment Resolution: 1/16" <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />I T1-87 <br />2 T2-91 <br />3 T3 -DSL <br />4 <br />Bucket Installation Type:10 <br />Direct Bury <br />❑ Contained in Sump <br />Direct Bury <br />Contained in Sump <br />ElDirect Bury <br />Contained in Sump <br />❑ Di -ect Bury <br />❑ Conta ned in Sum <br />Bucket Diameter: <br />11" <br />11" <br />Bucket Depth: <br />12" <br />13" <br />Wait time between applying <br />vacuum/water and start of test: <br />5 MIN <br />5 MIN <br />Test Start Time (Ti): <br />9:30 <br />11:15 <br />Initial Reading (Ri): <br />11.25" <br />12.25" <br />Test End Time (TF): <br />10:30 <br />12:15 <br />Final Reading (RF): <br />11.25" <br />12.25" <br />Test Duration (TI: — Ti): <br />1 HR <br />I HR <br />Change in Reading (RF —Rj): <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />0 <br />0 <br />Test Result: <br />r <br />Pass ❑ Fait <br />® Pass ❑ Fail: <br />❑ Pass ® Fail <br />❑ Pas, ❑Fail <br />k-Omments — (include information on repairs made prior to testing, and reccoinmended follotii,-irp,fbr,failed ic.:tc) <br />OPW BUCKETS `- <br />91 SPILL BUCKET FAILED, TIGHTENED LOOSE FILL ADAPTOR, RETESTED & PASSED <br />DSL BUCKET FAILED, FOUND CRACK ON BELOWS OF BUCKET, WILL NEED TO BE REPLACED <br />AND RETESTED <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 require nents. <br />Technician's Signature: p ,s' Date: 9/28/2015 <br />State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requiremer-s may be more <br />stringent. <br />Monitoring Certification Test Report <br />4 o1' 5 <br />