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0 6 <br />Spill Bucket Testing Report Form <br />This, form is intended for use by contractors performing annual testing of UST spill containment structures. The complete 1 loan and <br />printouts from tests (if'applicable), should he provided to the facility owner/operator for submittal to the local regulatort agenc_r. <br />1. FACILITY INFORMATION <br />Facility Name: ARCO AMPM Date of Testing: 10/1/2015 <br />Facility Address: 880 E VICTOR RD City: LODI <br />Facility Contact: KARAN Phone: 209-3REGHVE&,- <br />Date Local Agency Was Notified of Testing: Tuesday, September 29, 2015 <br />Name of Local Agency Inspector (if present dut°ing testing): ARTS VELOSO <br />Company Name: BZ Service Station Maintenance <br />Technician Conducting Test: JERAMY CUMMINS a,4e"i-- <br />Credential i2: <br />4Credentials': 0 CSLB Contractor ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other (:Specif0 <br />License Number(s): 433159 <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: ® Hydrostatic+ -�❑ Vacuum ❑ Other <br />Test Equipment Used: TAPE MEASURE Equipment Resolution: 1/16" <br />Identify Spill Bucket (By Tank <br />Number, .Stored Product, etc.) <br />1 T1 -DSL <br />2 <br />3 <br />4 <br />Bucket Installation Type: <br />Bucket Diameter: <br />®Direct Bury <br />❑ Contained in Surnp <br />11" <br />Direct Bury <br />Contained in Sump <br />❑Direct Bury <br />Contained in Sump <br />Di •ect Bury <br />Conta ned in Sump <br />Bucket Depth: <br />13" <br />Wait time between applying <br />vacuum/water and start of test: <br />5 MIN <br />Test Start Time (Ti): <br />9:45 <br />Initial Reading (Rj): <br />11.5" <br />Test End Time (TF): <br />10:45 <br />Final Reading (RF): <br />11.5" <br />Test Duration (TF — Ti): <br />1 HR <br />Change in Reading (RF —Rj): <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />0 <br />Test Result: <br />® Pass ❑ Fail <br />❑ Pass ❑Fall <br />❑Pass ❑Fail <br />❑ Pass ❑ Fail <br />�.ummenrs — (include information on repairs made prior to testing, and recommended,/blloil,-up./iu•,failed it ,ts�) <br />OPW BUCKETS _ <br />9/30/15 - DSL BUCKET DIRECT BURY BUCKET REPLACED BY MVP <br />10/1/15 - TEST AFTER REPLACEMENT, PASS <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />I hereby certify that all the informat' n contained in this report is true, accurate, and in full compliance with legal require nents. <br />Technician's Signature. Date: 10/1/2015 <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 />5of5 <br />