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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 (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: LODI CORP YARD I Date of Testing: 09-11-09 <br /> Facility Address: 1331 SOUTH HAM LANE LODI CALIFORNIA 95242 <br /> Facility Contact: RANDY/DENNIS Phone: 209-333-6830 <br /> Date Local Agency Was Notified of Testing:08-27-09 <br /> Name of Local Agency Inspector(if present during testing): SAN JAOQUIN CO ARIS <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2`1 Street Galt, CA 95632 (209)744-0112 Fax: (209) 744-0116 <br /> Technician Conducting Test: ❑ Lyle D.Nimmo ❑ Zane A.Nimmo ❑ David A. Winkler Z 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 H2O Equipment Resolution: 1/16 <br /> F <br /> dentify Spill Bucket(By Tank 1 87 2 DIE 3 87 4 <br /> umber, Stored Product, etc.) <br /> ® Direct Bury ® Direct Bury ® Direct Bury ❑ Direct Bury <br /> Bucket Installation Type: ❑ Contained in Sump ❑ Contained in Sump ❑ Contained in ❑ Contained in <br /> Sump Sum <br /> Bucket Diameter: l 1 12 11 <br /> Bucket Depth: 13 23 1/2 12 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 830 830 830 <br /> Initial Reading(Ri): 12 21 11 <br /> Test End Time(TF): 930 930 930 <br /> Final Reading(RF): 12 21 11 <br /> Test Duration(TF—Ti): 1 HOUR I HOUR I HOUR <br /> Change in Reading(RF-Rj): 0 0 0 <br /> Pass/Fail Threshold or 0 0 0 0 <br /> Criteria: <br /> Test Result: ® Pass ❑ Fail I [K Pass ❑ Fail ® Pass ❑ Fail ❑ Pass ❑ 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: 0 Date: 9/11/09 <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 />