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CEIVED <br /> S E P 19 2ORC13,January 2006 <br /> Spill Bucket Testing Report Form <br /> ENVIRONMENTAL <br /> This form is intended for use by contractors performing annual testing of UST spill contai� �A�eted form and <br /> printouts from tests(if applicable), should be provided to the facility owner/operator fors bmit a tot a Iota regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: CITY OF LODI I 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 4162"d 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: ® 1-Iydrostatic ❑ Vacuum ❑ Other <br /> Test Equipment Used: TAPE/H2O Equipment Resolution: 1/16 <br /> Identify Spill Bucket(By Tank1 87 2 87 3 DIESEL 4 <br /> 'umber, Stored Product, etc.) <br /> ] I I <br /> ® Direct Bury ® Direct Bury ❑Direct Bury Ll Direct Bury <br /> Bucket Installation Type: ®Contained in ❑ Contained in <br /> ElContained in Sump ElContained in Sump SumpSum <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): 1 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 />