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RECEIVEL <br />SWRCB, January 2006 <br />Spill Bucket Testing Report Form JAN 2 9 2015 <br />This form is intended for use by contractors performing annual testing of UST spill containment structu <br />NA <br />printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to th L, <br />NW <br />� r1�0AQT��c��T <br />1 Ti Ar1r11.TTV TN1Pn1QMATTnN <br />Facility Name: CHEROKEE LN SERVICE STATION Date of Testing: 10/28/14 <br />Facility Address: 900 S. CHEROKEE LN LODI .CA <br />Facility Contact: DALJIT Phone: <br />Date Local Agency WasNotified of Testing :10-15-14 <br />Name of Local Agency Inspector (if present during testing): <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: ®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 11 <br />A CPTT.T. RU KR.T TF.CTTNf_ 1N1RnRMATInN <br />Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: TAPE MEASURE <br />Equipment Resolution: 1/16 <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />187-A <br />2 87B <br />L <br />3 91 <br />4 DSL <br />Bucket Installation Type: <br />® Direct Bury <br />El Contained in Sump <br />® Direct Bury <br />❑Contained in Sump <br />® Direct Bury <br />F1 Contained in <br />Sump <br />® Direct Bury <br />❑ Contained in <br />Sum <br />Bucket Diameter: <br />1 1 <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 />-_ <br />-- <br />Test Start Time (TI): <br />830 <br />830 <br />830 <br />830 <br />Initial Reading (Ri): <br />11 <br />11 <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— Ti): <br />IHR <br />IHR <br />IHR <br />1 HR <br />Change in Reading (RF - RI): <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 />® 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; " 4741 -� 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 />