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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: 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(tf present during testing): ARTS <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 4162 nd 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 El Direct Bury <br /> Bucket Installation Type: ®1 Contained in El Contained in El in Sump El 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): 1 1 1 <br /> E V E.I V <br /> Initial Reading(RI): 14 12 23 0 CT 16 ?814 <br /> Test End Time(TF): 2 2 2 <br /> Final Reading(RF): 14 12 23 <br /> Test Duration(TF—TI): 1 HOUR 1 HOUR 1 HOUR NFITN r*=1j0T4AC1,1' <br /> Change in Reading(RF-RI): 0 4 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: 71 ® Pass ❑ Fail I ® Pass ❑ Fail 1 ® Pass ❑ Fail 1 ❑ Pass ❑ Fail <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: . vlz�—j 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 />