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SD <br /> Spill Bucket Testing Report ForB E C N 6 <br /> Thisform is intendedfor use by contractors performing annual testing of USTspil/containment structur*s,-va c7nWedform and <br /> printouts from tests(ifapplicable)should be provided to the facility owner/operatorfor submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATIONTH <br /> Facility Name: Valley Pacific Date o flog: <br /> Facility Address: 930E.Victor Rd.,Lodi,CA 95240 <br /> Facility Contact: Mike Eliason Phone: (209)993-8793 <br /> Date Local Agency Was Notified of Testing: 03113/17 @1:25pmvia email <br /> Name of Local Agency Inspector(ifpresent during testing): Garrett Backus @ San Joaquin E.H.D. <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: CGRS, Inc. <br /> Technician Conducting Test: RICHARD THOMAS <br /> Credentials': ® CSLB Contractor ®ICC Service Tech. ® SWRCB Tank Tester ❑Other(Spec) <br /> License Number(s): 803616(CSLB Contractor) -- 5254736 (ICC Service Tech.) — 06-1672(SWRCB Tank Tester) <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: M Hydrostatic ❑ Vacuum ❑ Other(Specify) <br /> Test Equipment Used:Tape Measure Equipment Resolution:+or-1116" <br /> Identify Spill Bucket(By Tank T-6 87 Fill T-7 87 Fill <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 Sump ❑Contained in Sump <br /> Bucket Diameter: 12" 12" <br /> Bucket Depth: 11 'All 11' <br /> Wait time between applying 10 min. 10 min. <br /> vacuum/water and start of test: <br /> Test Start Time(T[): 12:15pm 12:15pm <br /> Initial Reading(Rr): 11 1/:' 11" <br /> Test End Time(Tp): 1:15pm 1:15pm <br /> Final Reading(Rr): 11 1/." 11" <br /> Test Duration IT,—T,): 1 hr 1 hr <br /> Change in Reading(RF-R,): 0" 0" <br /> Pass Tail Threshold or Criteria: No Loss No Loss <br /> Test Result: 1 ® Pass ❑Fail ® Pass ❑Fail I ❑ Pass ❑Fail ❑ Pass ❑ Fail <br /> Comments—(include information on repairs made prior to testing, and recommendedfollow-upforfailed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all theinformationcontained in this report is true,accurate,and in full compliance with legal requirements.ei <br /> Technician's Signature: I �— vt� Date: 03120117 <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 />