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0 0 <br />Spill Bucket esting Report Form <br />This form is intendedfi)r use by annual testing of UST spill The compleled.fi)rn, und <br />prinfoulsfirom tests (d`f°qpplicahle), should be provided to thefttcili(y to the ktcal regulaton, crgencv, <br />1. FACILITY INFORMATION <br />Facility Name: ARC 1 0 .. AMPMDate ofTesting: 9/25/2014 <br />. ......... .. . . . .............. . . <br />Facility Address: 880 E VICTOR RD City: LODI <br />Facility Contact: KARANPhone: 209-369-0958 <br />.......... . . .. .... .......... <br />Date Local Agency Was Notified of Testing: Wednesday, September 24, 2014 ............ <br />Narne of Local Agency Inspector (efpraveni during, tevting)- JEFF WONG <br />. -QPVTXT4- A g—rt-tp fvvnD X4 ii TWIN <br />Vj3,1 11,4 %Y %-"I'l IL aws.- a <br />Company Name: 8Z Service Station Maintenance <br />-Technician Conducting Test: RHOME DESBIENS ............ <br />.... . ....... . ..... .... ... . . . ... ........... ........... ICC Service Tech, ------- ( (titer ecr1t9 <br />SW Tank-Tes <br />Credcn`t-ia-I;T� CSLB Contractor a' <br />. .. . . ......... . <br />License Number(s): 433159 <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: Z Hydrostatic Vacuum Other <br />.......... . .. -- — ---- <br />Test Equipment Used: TAPE MEASURE <br />identify Spill Bucket (lav ranA, <br />I T,3 -DSL <br />3 <br />4 <br />Number, Stored Produel, etc.) <br />... ......... <br />O'Direct Bury <br />��Diirect 8t�try <br />EFDirecl <br />I Ct Bury <br />Bucket installation Type: <br />ComainedinSunip <br />0 Contained in Surnp <br />. . ........ . <br />. d' S <br />Contained .. urnp j <br />.... . ......... . ........ <br />­-'----­-­­ ---- <br />Bucket Diameter: <br />_ _E) <br />........................ <br />Bucket Depth: <br />14.. . . . . . .. . .. <br />. ... . ................ <br />.. .. .......... <br />Dart time between applying <br />5 MIN <br />vacuum/water and start of test: <br />Test Start `Time (TI); <br />1:17 <br />. <br />. .............. <br />Initial Reading (Rj): <br />Z�- --- I- <br />Test End Time (T,,):2:17 <br />. . . . . ................. <br />. ......... . <br />Final Reading (Rr): <br />13" <br />. . . . . .. . ................................ <br />Test Duration (I -F -Ti): <br />I HR <br />. .................. - .................. .. ........ ....... . . . <br />Change in Reading (111 - R,j): <br />0 ............ <br />------- ................ <br />. . .............................. . <br />Pass/Fail Threshold or <br />. .... . <br />0 <br />Criteria: <br />_4 <br />L wf, 'esult: <br />T—e4Q�� <br />0 Pasi" 0 Fall <br />— <br />Pass E] fail <br />'n Pass El Fail <br />El Pass 0, Fail <br />j <br />Comments - (include in1bryzation on repairs made prior to tewing, and <br />OPW BtiCKETS <br />9/24/14 - REMOVED DRAIN. CLEANED O-RIN(j, RESEAI-UD, TIGFITFNFD BOLTS, Rl:-[T`sT', PASSED <br />9/25/14 - TESTED WITH INSPECTOR, PASSED <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE [,"OR CONDUCTINGTHIS TESTING <br />I hereby certify, that all the information contained in this report is true, accurate, and in full compliance with legal requiremcnts. <br />Technician's Signature:,..--...---,- Date: 9/25/2014 <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 <br />