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4 0 <br /> SWRCB, January 2006 <br /> Spry Bucket Testing Deport 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 thefacility owner/operator for submittal to the local regulatory agency.. <br /> I. FACILITY INFORMATION <br /> Facility Name: OASIS PLAZA VALERO 41 Date of Testing: 2/28/11 <br /> Facility Address: 800 S. CHEROKEE LN. LODI, CA 95240 <br /> Facility Contact: MIKE Phone: <br /> Date Local Agency Was Notified of Testi g:1/25/11 --_- <br /> Name of Local Agency Inspector (rf present during testing: AR[S CACAPIT <br /> 24 TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 4162 ad Street Galt, CA 95632 (209)744-0112 Fax: (209)744-0116 <br /> Technician Conducting Test: ❑ Lyle D.Nimmo ❑ Zane A.Nimmo ❑ David A. Winkler ❑ Felix G. Ramirez <br /> 5249115-UT 5263322-UT 5263373-UT 5273934-UT <br /> Lcredejjtials': Z ICC Service Tech. SWRCB Tank Tester <br /> 3 SPILT,BUCKET TESTING INFORMATION <br /> Test Method Used: Z Hyd ostatic ❑ Vacuum ❑ Other <br /> Test Equipment Used: TAPE MEASURI{, H2O Equipinent Resolution: 1/16" <br /> Identify Spill Bucket (By Tank 1 87 2 3 91 4 'DIESEL _� ---- <br /> Number, Stored Product, etc.) <br /> ® Direct Bury Direct Bury ® Direct Bury ® Direct Bury <br /> Bucket Installation Type: El Contained in El Contained in <br /> ❑ <br /> Contained in Sump ElContained in Sump Sump Sum <br /> Bucket Diameter: 11 1 l 1 1 — <br /> Bucket Depth: 12 1/2 13 15 1/2 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 0900 0900 0900 <br /> Initial Reading(R]): 11 1/2 12 14 1/2 <br /> Test End Time(TF): 1000 1000 1000 <br /> Final Reading(RF): 11 1/2 12 14 1/2 <br /> Test Duration(TF—Tj): HR HR HR HR <br /> Change in Reading(RF-Rt): 0 0 0 _ <br /> Pass/Fail Threshold or _- _- <br /> criteria: — <br /> Test Result• Z P A ss ❑ Fail ❑ Pass ❑ Fail I ❑ Pass ❑ Fail � Pass ❑ Fail <br /> Oommcnts— (include information on repairs made prior to testing, and recommended_follow-up for failed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the information coIptained in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: Date: 2/28/1 1 <br /> State laws and regulations do not currel tly require testing to be performed by a qualified contractor. However, local requirements <br /> may be more stringent. <br />