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w • RECEIVED <br />Spill Bucket Testing Report Form FEB 2,0 2-015 <br />This fibrin is intended, fbr use by, vonircactors pe fbrming annual testing of NT shill con"ainment structurcr � '06 ted f i>rnt arae! <br />l rixrtot£fs from tests (if applicable), should he provided to the f icility� ctst�rrer, a/��,>c�r�axtrar filr submittal to the r <br />MENTAL <br />1. FACILITY INFORMATION ` ►1 d �w wry <br />Date of Testing: 9/25/2014 <br />I acility Name: ARC(? AMPM ._.:._: <br />Facility Address: 880 E VICTOR RD City. LOD1 <br />Facility Contact: iKARANPhone: 209-369-0958 <br />............. _..__ �.. <br />Date Local Agency Was Notified of Testing: Wednesday, September 24 2014 <br />Narne of Local Agency Inspector (If pr(nent curring lalling). JEFF WONG <br />2. TF.S'CING CONTRACTOR INFORMATION <br />CompanyName: [I'LService Station Mainlence .......... <br />`i.echnicianConductingTest RH©MF DESDIENS <br />Credentials`: CSLB Contractor �IC.E Service Tech. Sl itC°i3 Tank I ester Other t 5l>ec r1i'1 <br />License Number(s):� 433159 � _ <br />3. SPILL BUCI{ET rFSTING INFORMATION <br />Test Method Used.: <br />® Hydrostatic <br />Q Vacuum <br />[ Other <br />Test Equipment Used: TAPE. MEASURE <br />Equipment Rc oluttow <br />1/16 <br />Identify Spill Bucket (By Tank <br />1 T3 -DSL <br />2 <br />3 <br />4 I <br />Nzarn/aer„ Stored T'rvcfz£c�t, etc. <br />� <br />�_ <br />Bucket Installation Type: ; <br />Direct Bury <br />Contained in Sum�..... <br />Direct Buryt�i�ect <br />Q..Contained to Sunt <br />Finny; <br />j C ontalnod to Sum❑ <br />f t.iircet l3€iry <br />Contained ill �itktl <br />Bucket Diameter: <br />11" _ <br />_..._. <br />Bucket Depth: <br />14" <br />_._........_ <br />h <br />_......._...._.....__.. <br />F <br />Wait time between applying <br />. <br />y MIN <br />__............................. <br />vacuuml,A=titer and start of test: <br />Test Start Time (Tj). <br />1:17 <br />Q <br />.......... <br />Initial Reading (Ri): <br />_ <br />Test fend Time (T,,.): <br />13" <br />__.._. .................. <br />2.17 <br />_.___ <br />._._.....___ <br />Final Reading (Rj): <br />13" <br />Test Duration (TF --T,): <br />1 HR <br />Q <br />- --l", --- <br />Change in Reading (k- R 1): <br />tl <br />Pass/Fail Threshold or <br />0 <br />i <br />Criteria: <br />Test Result- <br />I Dass ❑ F ii <br />_ <br />F a<I <br />Piss FsI1 <br />Comments — {include information on repairs made prior to testinjc, itr7d YG'C'f3mYlrE'r7Llad f�Jl/(tai'-2£p ff>r f(£tl�'tl te?St4J <br />OPW BUCKETS <br />1/24,14 -REMOVED DRAIN, CLEANED O-RING, RESEALED, TIf11-I"1 FNED 1301,TS, RF'IF`,ST. P.ASSF D <br />1./25/14 TESTED WITH INSPECTOR, PASSED <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE" FOR CONDI CTING "ITHIS `i S`L'ING <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: <br />Date: 9/25/7-014 <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 />5of5 <br />