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SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intended for use by contractors performing annual testing of UST spill containment structures. The completed form and <br /> printouts from tests(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1.FACILITY INFORMATION <br /> Facility Name:Love's County#538 Date of Testing:4/14/2020 <br /> Facility Address: 15250 Thornton Rd,Lodi,CA 95242 <br /> Facility Contact: Phone: -- <br /> Date Local Agency Was Notified of Testing:4/7/2020 <br /> Name of Local Agency Inspector(if present during testing):Paul Nso <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name:TANKNOLOGY INC. <br /> Technician Conducting Test:Clint Fuhrman <br /> Credentials): F- CSLB Contractor FV ICC Service Tech. r SWRCB Tank Tester F Other(Specify) <br /> License Number(s): 9160945 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used By: F Hydrostatic F Vacuum Other <br /> Test Equipment Used:LAKE TEST Equipment Resolution:0.0625 in. <br /> Spill Box#Tank TI Spill Box#Tank T2 Spill Box#Tank T3 Diesel- <br /> Identify Spill Bucket(By Tank UNLEADED-Fill 1 -Direct PREMIUM-Fill 1-Direct- Fill 1 -Direct-Grade level Spill Box# <br /> Number,Stored Product, etc.) -Grade level in Grade level in containment <br /> containment sump sump in containment sump <br /> C Direct Bury C Direct Bury C Direct Bury f Direct Bury <br /> Bucket Installation Type: ro Contained in Sump (: Contained in Sump C• Contained in Sump f Contained in Sump <br /> Bucket Diameter: 12.00 12.00 12.00 <br /> Bucket Depth: 14.00 14.00 14.00 <br /> Wait time between applying <br /> 5 min 5 min 5 min min <br /> vacuum/water and start of test <br /> Test Start Time(Tl): 09:30:00 09:20:00 09:25:00 <br /> Initial Reading(Rl): 10.50 in. 10.50 in. 10.50 in. <br /> Test End Time(TF): 10:30:00 10:20:00 10:25:00 <br /> Final Reading(RF): 10.50 in. 10.50 in. 10.50 in. <br /> Test Duration(TF—Tl): 1 hr 1 hr 1 hr <br /> Change in Reading(RF—Rl): 0.00 in. 0.00 in. 0.00 in. <br /> Pass/Fail Threshold or Criteria: +/-0.00 +/-0.00 +/-0.00 +/ <br /> Test Result: Pass Pass Pass <br /> Comments-(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> CERTIFICATION OF TECI INICIAN 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 requirements. <br /> Technician's Signature: �✓ '� Date: 4/14/2020 <br /> 'State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements may be more stringent. <br /> WO:2345989 <br />