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. REQ VED <br /> R"q,1J4 h 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intended for use by contractors performing annual testing of UST spill containment st (Wss:'The completed forlriAJH <br /> printouts from tests(f applicable), should be provided to the facility owner/operator for submittal to the local regulatory ffgfy. <br /> 1. FACILITY INFORMATION <br /> Facility Name: CHEROKEE ARCO I Date of Testing: 10-17-16 <br /> Facility Address: 900 S CHEROKEE LANE LODI CA 95240 <br /> Facility Contact: DALJIT Phone: 209-334-3129 <br /> Date Local Agency Was Notified of Testing:09-24-16 <br /> Name of Local Agency Inspector(fpresent during testing): SAN JOAQUIN CO <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2nd 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 Junk 1 87 2 87 3 91 4 DIL <br /> Number, Stored Product, etc. <br /> ®Direct Bury ®Direct Bury ® Direct Bury ® Direct Bury <br /> Bucket Installation Type: El Contained in El Contained in <br /> El Contained in Sump El Contained in Sump Sump Sum <br /> Bucket Diameter: 11 11 11 11 <br /> Bucket Depth: 13 13 13 13 <br /> Wait time between applying _ <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 1300 1300 1300 1200 <br /> Initial Reading(Ri): 13 13 13 13 <br /> Test End Time(TF): 1400 1400 1400 1400 <br /> Final Reading(RF): 13 13 13 13 <br /> Test Duration(TF—TI): 1 HOUR 1 HOUR 1 HOUR I HOUR <br /> Change in Reading(RF-Rt): 0 0 0 0 <br /> Pass/Fail Threshold or 0 0 0 0 <br /> Criteria: <br /> Test Result: ® Pass ❑ Fail ® Pass ❑ Fail ® Pass ❑ Fail ® Pass ❑ Fail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> OPW BUCKETS _ <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 kith le„al requirements. <br /> Technician's Signature: Date:10-17-16 <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 />