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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(if 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 CORP YARD I Date of Testing: 9/16/11 <br /> Facility Address: 1331 S. HAM LN. LODI, CA 95240 <br /> Facility Contact: RANDY Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(ifpresent during testing): ARIS C. <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. E SWR1'-B Tann.Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ® Hydrostatic ❑ vacuum ❑ Other <br /> Test Equipment Used: TAPE MEASURE, H2O Equipment Resolution: 1/16" <br /> Identify Sp7"rype- <br /> 1 87 10K 2 87 2K 3 4 DIESEL <br /> Number, St <br /> Direct Bury Direct Bury <br /> Bucket Ins ®Direct Bury ® Direct Bury ❑ Contained in <br /> ❑ Contained in Sump ❑Contained in Sump El Contained in <br /> Sump Sum <br /> Bucket Diameter: 12 12 12X15 <br /> Bucket Depth: 14 12 24 <br /> Wait time between applying <br /> vacuum/water and start of test: -- -- <br /> Test Start Time(Tj): 0920 0920 0920 <br /> Initial Reading(RI): 12 7/8 12 1/2 22 <br /> Test End Time(TF): 1020 1020 1020 <br /> Final Reading(RF): 12 7/8 12 1/2 22 <br /> Test Duration(TF—Tj): HR HR HR HR <br /> Change in Reading(RF-Rj): 0 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: -- -- -- <br /> Test Result: ®'Pass. ❑Fail �.Pass . [IF 'I ❑ Pass ❑Fail ® Pass El 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: 9-16-11 <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 />