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' • 0 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: OASIS PLAZA VALERO Date of Testing: 2-25-10 <br /> Facility Address: 800 S CHEROKEE LN LODI CA <br /> Facility Contact: MIKE Phone: <br /> Date Local Agency Was Notified of Testing : <br /> Name of Local Agency Inspector (fpresent during testing): TWI <br /> 7.. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST' 416 2°d Street Galt,CA 95632 (209) 744-01 12 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 /> Credentials': E ICC Service Tech. SWRCB Tank Tester <br /> :1. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br /> "fest Equipment Used: h20 and tape measure Equipment Resolution: 1/16 <br /> Identify Spil�Bucket (By nk 1 87 2 9t '� DSL - 4Nurrrbc�r, Sto . <br /> Direct Bur Direct Bury ® Direct Bury ❑ Direct Bury <br /> Bucket Installation Type: y E3 Contained in ❑ Contained in <br /> [� Contained in Sump ❑ Contained in Sump Sum Sum <br /> Bucket Diameter: 11 I I 11 <br /> Bucket Depth: 12.50 12.50 15.50 <br /> Wait time between applying -- <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 900 900 900 <br /> Initial Reading(R,): <br /> 11.50 11.50 14 <br /> Test End Time(TF): 1000 1000 1000 <br /> Final Reading(RF): 11.50 11.50 14 <br /> Test Duration(TF—Tj): IHR IHR 1 HR <br /> Change in Reading(RF-R,): 0 0 0 <br /> Pass/Fail Threshold or 1/16 1116 1/16 <br /> Criteria: <br /> Test Result: JZ Bass El Ford ® Pass ❑ Fail Pass ❑ Fail E] Pass ❑ Fail <br /> Comments— (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 contained in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: <br /> --�� Date 2-25-2010 <br /> ' State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements <br /> may be more stringent. <br />