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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 (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1 _ FA('TT.TTV TNTiYI1D1%4ATT(11V <br />Facility Name: CHEROKEE LANES SVC ARCO Date of Testing: 1-26-11 <br />Facility Address: 900 S CHEROKEE LANE LODI CA <br />Facility Contact: DARJEET Phone: <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (rf'present during testing): ARIS <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 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 1: ® ICC Service Tech. Z SWRCB Tank Tester 11 <br />3. SPILL Ri1CKFT TF.STTNC:' INFORMATION <br />'fest Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: h20 and tape measure Equipment Resolution: 1'16 <br />Identify Spill Bucket (By Tank1 <br />Number, Stored Product, etc.) <br />87 1 <br />C <br />2 872 <br />3 91 <br />4 DSL <br />Bucket Installation Type: <br />Yp <br />Direct Bur <br />® Y <br />❑Contained in Sum <br />Sump <br />®Direct Bury <br />El in Sump <br />® Direct Bury <br />❑Contained in <br />Sump <br />® Direct Bury <br />❑ Contained in <br />Sum <br />Bucket Diameter: <br />11 <br />I 1 <br />11 <br />12 <br />Bucket Depth: <br />12 1/4 <br />14 <br />14 1/2 <br />103/4 <br />Wait time between applying <br />vacuum/water and start of test: <br />-- <br />-- <br />Test Start Time (Ti): <br />1 845 <br />845 <br />845 <br />845 <br />Initial Reading (Rj): <br />12 <br />13 1/4 <br />13 1/2 <br />103/4 <br />Test End Time (TF): <br />945 <br />945 <br />945 <br />945 <br />Final Reading (RF): <br />12 <br />13 1/4 <br />13 1/2 <br />103/4 <br />Test Duration (TF — Ti): <br />1 HR <br />IHR <br />IHR <br />IHR <br />Change in Reading (RF - Ri): <br />0 <br />0 <br />0 <br />O <br />Pass/Fail Threshold or <br />Criteria: <br />Test Result: <br />El Pass ❑ Fail <br />❑ Pass ❑ Fail <br />® Pass ❑ Fail <br />Z 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 />1 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 : 1/26/11 <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 />