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IV �L.-O, <br /> SEP 249' .Ianuary 2006 <br /> Spill Bucket Testing Report Form <br /> VITAL HEALTH <br /> This form is intended for use by contractors performing annual testing of UST spill containmall/ [ iihc c�,�� form and <br /> printouts from tests(if applicable), should be provided to the facility owner/operator for subs itt u!tot RN�itil�ory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: CITY OF LODI Date of Testing: 09-16-16 <br /> Facility Address: 1331 S HAM LANE LODI CA 95240 <br /> Facility Contact: RANDY Phone: 209-333-6830 <br /> Date Local Agency Was Notified of Testing:08-24-16 <br /> Name of Local Agency Inspector(f present during testing): SAN JOAQUIN CO <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: TAPE/H2O Equipment Resolution: 1/16 <br /> Identify Spill Bucket(By Tank 1 87 2 87 3 DIESEL 4 <br /> Number, Stored Product, etc.) <br /> ® Direct Bury ® Direct Bury ❑Direct Bury ❑ Direct Bury <br /> Bucket Installation Type: ® Contained in El Contained in <br /> ❑ Contained in Sump EJ Contained in Sump Sump Sum <br /> Bucket Diameter: 11 11 12X15 <br /> Bucket Depth: 14 12 24 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 1300 1300 1300 <br /> Initial Reading(RI): 14 12 23 <br /> Test End Time(TF): 1400 1400 1400 <br /> Final Reading(RF): 14 12 23 <br /> Test Duration(TF—TI): I HOUR 1 HOUR 1 HOUR <br /> Change in Reading(RF-RI): 0 0 0 <br /> Pass/Fail Threshold or <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 /> 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: Date:09-16-16 <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 />