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�REC 2006 <br /> > rY <br /> Spill Bucket Testing Report Form NOV 04 2015 <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(fapplicable), should be provided to the facility owner/operator for subnENVHQNMEr4aiAgency. <br /> 1.FACILITY INFORMATION 149:AIT4l n=Aal"pMT <br /> Facility Name: WINE COUNTRY 76 Date of Testing: 10-9-15 <br /> Facility Address: 1111 E KETTLEMEN LANE LODI CA <br /> Facility Contact: Sandeep Singh Phone: 369-3633 <br /> Date Local Agency Was Notified of Testing :10-1-15 <br /> Name of Local Agency Inspector(if present during testing): <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2nd 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: h20 and tape measure Equipment Resolution: 1/16 <br /> Identify Spill Bucket(By Tank 1 87 2 91 3 DSL 4 <br /> Number, Stored Product, etc. <br /> [D Direct Bury ❑Direct Bury <br /> Bucket Installation Type: ®Direct Bury ®Direct Bury E]Contained in El Contained in <br /> ❑Contained in Sump ❑Contained in Sump Sum Sum <br /> Bucket Diameter: I I 11 11 <br /> Bucket Depth: 14 14 14 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 9 9 9 <br /> Initial Reading(RI): 13 13.50 13.50 <br /> Test End Time(TF): 10 10 10 <br /> Final Reading(RF): 13 13.50 13.50 <br /> Test Duration(TF—TI): IHR IHR IHR <br /> Change in Reading(RF-RI): 0 0 0 <br /> Pass/Fail Threshold or 1/16 1/16 1/16 <br /> Criteria: <br /> Test Result: ® Pass ❑Fail ® Pass ❑ Fail ® Pass ❑Fail ❑ Pass ❑Fail <br /> Comments—(include information on repairs made prior to testing and recommended follow-up for failed tests) <br /> OPW <br /> CERTIFICATION OF I ECI INICLU RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that an the infoor�m��aatiou contained in Ibis report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: Date 10-9--2015 <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 />