Laserfiche WebLink
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: CITY OF LODI' Date of Testing: 09-25-14 <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:9-19-14 <br /> Name of Local Agency Inspector(ifpresent during testing): ARIS <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: ® 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 /> Nznnber, Stored Product, etc.) <br /> ® Direct Bury ®Direct Bury <br /> ❑Direct Bury ❑ Direct Bury <br /> Bucket Installation Type: ®Contained in El Contained in <br /> El Contained in Sump El Contained in Sump Sump Sum <br /> Bucket Diameter: 1 1 11 16 <br /> 11 Ir— <br /> Bucket Depth: 14 12 24 1 V CE) <br /> Wait time between applying _ <br /> vacuum/water and start of test: <br /> Test Start Time(Tj): 1 1 I <br /> Initial Reading(111): 14 12 23 <br /> Test End Time(TF): 2 2 2DE PAQTAAr—Ki-r <br /> Final Reading(RF): 14 12 23 <br /> Test Duration(TF—Tj): 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 I ® Pass ❑ Fail I ® Pass ❑Fail ❑ Pass ❑ bail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> ALL PASSED <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:09-25-14 <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 />