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150310-428 <br /> 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: Lodi CA FO Term (Intl) I Date of Testing:4-2-2015 <br /> Facility Address: 2500 West Turner Road <br /> Facility Contact: Denise Grisko Phone: 916-205-9291 <br /> Date Local Agency Was Notified of Testing: 48hrs prior <br /> Name of Local Agency Inspector(i resent during testi! ): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Sunwest Engineering Inc <br /> Technician Conducting Test: David Smith <br /> Credentials : CSLB Contractor[] ICC Service Tech. l SWRCB Tank Tester(]Other (Sp''ec4 ) 'N"40rq <br /> License Number(s): 8260473 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: lake hydrostic <br /> Test Equipment Used:tape measure IJ visual - <br /> Identify Spill Bucket(by Tank tank 1 diesel <br /> Number, Stored Product etc. <br /> Direct Bury irect Bury irect Bury irect Bury <br /> Bucket Installation Type: ntained in Sum ontained in Sum ontained in Sum ontained in Stun <br /> Bucket Diameter: 12" <br /> Bucket Depth: 13' <br /> Wait time between applying 15 min <br /> vacuum water and start of test: <br /> Test Start Time(TI), 09:15 am <br /> Initial Reading(RI): 1.25 below finish grad <br /> Test End Time(TF): 10:15 am <br /> Final Reading(R F): 1.25 below finish grad <br /> Test Duration(TF-Ti): 1 hr <br /> Change in Reading(R r Ri): 0 <br /> Pass/Fail Threshold or 0002 <br /> Criteria: <br /> Test Results pass <br /> Comments - (include information on repairs made prior to testing, and recommendedfollow-u or 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 /> Digitally signed by Smith David for WT#150310 428 <br /> Technician's Signature: 041022201512;32.25 Date: 4,1212015 <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 /> 0A/0C APPROVED <br /> 4/22/201512:07 PMMike P. <br />