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OCT-27-2008 18:29 CIT`' OF LODI 209 333 5710 P.50 <br /> SWRCB, January 2006 <br /> r Spill Bucket Testing Report Form <br /> This form is intended for use by contractors performing annual testing of(IST spill containment structures. Theme pled or nd <br /> printouts from tests(If applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> _ ...a <br /> .a� 1. FACILITY INFORMATION ti <br /> / Date of Testing: <br /> Facility Name: CA <br /> Facility Address: 371 <br /> Facility Phone:Contact: i S <br /> Date Local Agency Was Notified of Testing : <br /> Name of Local Agency Inspector(f present during testing): <br /> 2.'RTES-MG CONTRACTOR INFORMATION <br /> „d 09 744-0112 Fax:(209)7440116 <br /> Company Name: AFFORDA TEST 416 2 Street Galt,CA 95632 (2 ) <br /> ❑ Lyle D.Nimrno C] Zane A.NimmoDavid A.Winkler ❑ <br /> Felix G.Ramirez <br /> Technician Conduefu)g Test: 5249115-UT 5263322-UT 5263373-UT 5273934-UT <br /> ' <br /> Credentials': ❑ ICC Service Tech. SWRCB Tank Tester 0 ^� <br /> 3.SPILL BUCKET TESTING FORMATION <br /> drostatic ❑ Vacuum Other <br /> Test :q <br /> ethod Used: y Equipment Resolution.- <br /> 4 <br /> esolution; <br /> Test Equipment Used: a .,,:,_.... .._., <br /> T <br /> y .M............. <br /> . <br /> Identify Spill Bucket(By Tank 1 OS L <br /> Number, Stored Product, etc. Direct Bury Lj Dict Bury <br /> Direct Bury ® Direct BuryContained in ❑Contained in <br /> ❑ <br /> Bucket Installation Type= ❑ Contained in Sump ❑Contained in Sump SumpS <br /> Bucket Diameter; <br /> 2 Z1 . <br /> Bucket Depth:ait time between applying i;5t <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 1 -j <br /> Initial Reading(Ret): <br /> Test End Time(TF): <br /> Final Reading(RF); <br /> Test Duration(TF—TJ: <br /> Change in Reading(RF-Rj): <br /> Pass/Fail Threshold ar <br /> ail <br /> Criteria: 1r' � ass. .[]Fail ass ❑Fah Pass ❑tail .❑�, O <br /> Test Result ;.;;.,.:,':..,..y,•;:• <br /> Comments-- include in ormcrtion on repairs made prior to test'P19, and recommended allow-u or ailed tests <br /> CERTIFICATION OF TE 1CIAN RES NSIBLE FOR ONDUCTING THIS TESTING <br /> I her+ y certify that all the in <br /> ntion contained in is report is t e accurate,and in full compliance with legal requirements. <br /> Date: <br /> Technician's Signature: 1 re uric testis to be performed by a qualified contractor•Ho r.... _. <br /> �..... <br /> Wever,local requirements <br /> ' State laws and regulations do t currently q $ <br /> may be more stringent. <br /> TOTAL P.50 <br />