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Spill Bucket Testing Report Form SWRCB,January 2006 <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 /> 4(iffpresent <br /> ORMATIONFacility Name: & SONS ate of Testing: 4/4/13 <br /> Facility Address: ST. LODI,CA 95240 <br /> Facility Contact: Phone: 209-368-0634 <br /> Date Local Agency Was ng:3/29/13Name of Local Agency Int during testing): ARIS <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2""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 /> Credentials': ® ICC Service Tech. ® SWRCB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ®Hydrostatic ❑ Vacuum ❑Other <br /> Test Equipment Used: TAPE MEASURE, H2O Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By Tank I KEROSENE 2 110 OCTANE 3 4 <br /> Number, Stored Product, etc) <br /> Bucket Installation Type: ®Direct Bury ®Direct Bury ❑ Direct Bury ❑ Direct Bury <br /> ❑ Contained in Sump ❑ Contained in Sump ❑ Contained in ❑Contained in <br /> Bucket Diameter: 12 12 Sum Sum <br /> Bucket Depth: 12 12 <br /> Wait time between applying <br /> vacuum/water and start of test: -- <br /> Test Start Time(Tj): 0930 0905 <br /> Initial Reading(R): 11-- 11-- <br /> Test End Time(TF): 1030 1005 <br /> Final Reading(RF): 11-- 2[1Fail <br /> 11-- <br /> Test Duration(TF—T�) HR HR <br /> Change in Reading(RF-Ri): 0 0 <br /> Pass/Fail Tbreshold or <br /> Criteria: -- -- <br /> Test Result: ® Pass ® Pass ❑Fail ❑ Pass ❑Fail ❑ Pass <br /> =E] 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:_ Date: 4-4-13 <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 />