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4 t. <br />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: CHEROKEE LN SERVICE STATION Date of Testin <br />Facility Address: 900 S. CHEROKEE LN LODI .CA <br />Facility Contact: DALJIT Phone: <br />Date Local Agency Was Notified of Testing :10-15-14 <br />Name of Local Agency Inspector (tf present during testing): <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: ®Ed Stearns ❑ Lyle D. Nimmo ❑ Zane A. Nimmo ❑ David A. Winkler ❑ Felix G. Ramirez <br />5250492 -UT 5249115 -UT 5263322 -UT 5263373 -UT 5273934 -UT <br />Credentials': ® ICC Service Tech. ® SWRCB Tank Tester <br />3_ SPI1,I, RITCKFT TESTING INFORMATION <br />Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: TAPE MEASURE Equipment Resolution: 1/16 <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />1 87-A <br />2 87B <br />3 91 <br />4 DSL <br />Bucket Installation Type: <br />®Direct Bury <br />❑ Contained in Sump <br />®Direct Bury <br />❑ Contained in Sump <br />® Direct Bury <br />❑ Contained in <br />SumpSum <br />® Direct Bury <br />❑ Contained in <br />Bucket Diameter: <br />11 <br />11 <br />11 <br />11 <br />Bucket Depth: <br />12 <br />12 <br />12 <br />11 <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (Tj): <br />830 <br />830 <br />830 <br />830 <br />Initial Reading (Rj): <br />11 <br />1 1 <br />11 1/2 <br />10 <br />Test End Time (TF): <br />930 <br />930 <br />930 <br />930 <br />Final Reading (RF): <br />11 <br />11 <br />11 1/2 <br />10 <br />Test Duration (TF — Tj): <br />IHR <br />IHR <br />IHR <br />IHR <br />Change in Reading (RF - Rj): <br />0 <br />0 <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />1/16 <br />1/16 <br />1/16 <br />1/16 <br />Test Result. <br />® Pass ❑ Fail <br />1 ® Pass ❑ Fail <br />® Pass ❑ Fail <br />® 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: es�?.. <br />Date: 10/28/14 <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 />