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R L 3"' E I V E D <br />(� � 1 2 `l �'� S W RCB, January 2006 <br />Spill Bucket Testing Report Forli� <br />This form is intended for use by contractors performing annual testing of UST spill ¢3r=NWN7fi4Jwnp1e1edform and <br />printouts from tests (f applicable), should be provided to the facility owner/operatolMPte'( OTegulatory agency. <br />IM 9 -TN 111 111`fi 1010111965 KTA Y [17►1 <br />Facility Name: CHEROKEE LANES SVC ARCO Date of Testing: 10-29-2013 <br />Facility Address: 900 S CHEROKEE LANE LODI CA <br />Facility Contact: DARJEET Phone: <br />Date Local Agency Was Notified of Testing :10-16-13 <br />Name of Local Agency Inspector (if present chiring testing): GARRET <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: AFFORDA TEST 416 2°' Street Galt, CA 95632 (209) 744-0112 Fax: (209) 744-0116 <br />Technician Conducting Test: ❑ Lyle D. Nimmo ❑ Zane A. Nimmo E David A. Winkler E Felix G. Ramirez <br />5249115 -UT 5263322 -UT 5263373 -UT 5273934 -UT <br />Credentials: E ICC Service Tech. E SWRCB Tank Tester <br />3_ CPTT.I, RTTC11CIPT TFNTING TNFORMATION <br />Test Method Used: E Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: h20 and tape measure Equipment Resolution: 1/16 <br />Identify Spill Bucket (/Sv lank <br />V'umber, Stored Prochtct, etc.) <br />1 871 <br />2 872 <br />3 91 <br />4 DSL <br />Bucket Installation Type:ElContained <br />E Direct Bury <br />❑Contained in Sump <br />E Direct Bury <br />El Contained in Sump <br />® Direct Bury <br />in <br />Sump <br />E Direct Bury <br />El Contained in <br />Sum <br />Bucket Diameter: <br />11 <br />I 1 <br />I I <br />11 <br />Bucket Depth: <br />12 <br />14 <br />15 <br />10 <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (Tt): <br />2 <br />2 <br />2 <br />2 <br />Initial Reading (Rt): <br />11 <br />13 <br />14 <br />9.50 <br />Test End Time (TF): <br />3 <br />32 <br />3 <br />3 <br />Final Reading (RF): <br />11 <br />13 <br />14 <br />9.50 <br />Test Duration (TF — Tl): <br />IHR <br />1 HR <br />IHR <br />IHR <br />Change in Reading (RF - Rt): <br />0 <br />0 <br />0 <br />O <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 />E Pass ❑ Fail <br />E Pass ❑ Fail <br />E Pass ❑ Fail <br />Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />OPW FLAPPERS <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 10-29-2013 <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 />