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i <br /> L SWRC�, Jant4ary 2006 <br /> Sp> ll Bucket Testing Report Form <br /> This form is Intended for use by contra.. »t <br /> ?rs performing annual testing of UST spill containent yi uctures. 7 he completed form and <br /> printouts from tests (t(applicable), shot d be provided to the facility owner/operator for submittal ro the local regulatory[agency. <br /> �. FACILITY INFORMATION <br /> FacilityNamc: OASIS PLA; k VAL13R0 Date df Testi g: 2-25-10 <br /> Facility Address: 800 S CREW KEE LN LODI CA <br /> Facility Contact: MIKE - Phone: <br /> Date Local Agency Was Notified of Te: ng: <br /> Natne of Local Agency Inspector(if pre. !nt during testing): TWI <br /> . TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TES 416 2nd Street Gait,CA 95632 (209)744-0112 Fax: (209)744-01)6 <br /> Technician Conducting rest: C r •yle D.Nimmo ❑ Zane A_Nitnmo � David A. Winkler [] Felix G.Ramiro <br /> _... .. 5.249-143-6f 5263322-U� . .. .. 5'.633: l� .X273934.1.11" <br /> Credentials: TCC Service Tech. ; Z S WRCB Tank Tester <br /> . SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: H,y rostatic Ll Vacuum Other <br /> Test Equipment Used: h20 and tape me ;ure Equipment <br /> 1t <br /> $ ui mens solution: 1/16 <br /> Emu <br /> ldemify Spill Bucket{By Tank 1 S7 2 91 3 DSL, 4 <br /> Number, Stared Product, etc. <br /> Direct$ Direct Bury <br /> Bucket Installation Type: ® D'> ct Bury Direct Bury <br /> ❑ <br /> ❑Containe in ❑ Contained in <br /> ❑ Coi tained in Sump ❑ Contained in Sump gum Sum <br /> Bucket Diameter: <br /> Bucket Depth: 12.50 12.50 LS.S4 <br /> 1 <br /> Wait time between applying -- <br /> vacuum/water and start of test; ----- <br /> Test Start Time(TO: 900 900 900 <br /> Initial Reading(Ri): 71,501 )1.50 14 <br /> Test End Time(TF): 1000 1040 1400 <br /> Final Reading(RF): 11.SQ a 11.50 14 <br /> Test nuration(TF—TI): l HR 1 HR 1HR <br /> Change in Reading(Rj;-Ri): 0 4 0_- <br /> PasslFail Threshold or 1/16 1116 1116 <br /> criteria. - <br /> ')<'esk, e�ult, <br /> ass' FaF1` "bass'., ;'1x11 � )Pss FSI,; L) Pass ❑,Fail <br /> Comments— (Include information oY Sew rs made prior to testing, and recommended allow-u or ailed testis) <br /> CERTIFICATION OF TECHWICIAN ;ESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I htrtby certify that all tht infoemarton contei ea in this repan Ig true,arrurite,9nd in fuli compliance with legal i eqiiii-ements, <br /> I <br /> TeG11i1lClStt'S S1gtlatLLrt:: <br /> Date 2-25-2014 <br /> State laws and regulations do not cur=j ntly require testing to be performed by a qualified eontrac or.However, local requirements <br /> may be more stringent. <br /> VO 39acJ SISCC]/olnb icio-1 no 88BL69ESOZI ST :Ze 0TeZ/9Z/Ee <br />