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FECEIVED <br /> NN v 2 "SW°RCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> ��n� nI ALTH <br /> This form is intended for use by contractors performing annual testing of UST spill contaNVARQ1�,'txi' .'T eAL H eted form and <br /> printouts from tests(f applicable), should be provided to the facility owner/operator for submitta��i ory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: CHEROKEE ARCO Date of Testing: 10-26-17 <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:09-27-17 <br /> Name of Local Agency Inspector(tf present during testing): SAN JOQUIN CO ELIANNA FLORIDO <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2°d Street Galt,CA 95632 (209)744-0112 Fax:(209)744-0116 <br /> ❑Ed Sterns ❑ Zane A.Nimmo ❑ David A.Winkler ® Felix G.Ramirez <br /> Technician Conducting Test: 814188-UT 8211269-UT 5263373-UT 5273934-UT <br /> Credentia ❑ ICC Service Tech. ❑ SWRCB Tank Tester <br /> Is': <br /> 3. SPILL BUCKET TFSTING INFORMATION <br /> Test Method Used: ®Hydrostatic ❑ Vacuum ❑ Other <br /> Test Equipment Used: TAPE/H2O I Equipment Resolution: 1/16 <br /> Identify Spill Bucket(By Tank 1 87 2 87 3 91 4 DIE <br /> Number, Stored Product, etc. <br /> ®Direct Bury ®Direct Bury ® Direct Bury ®Direct Bury <br /> Bucket Installation Type: El Contained in E] Contained in <br /> El Contained in Sump ❑ 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): 1 13 13 13 13 <br /> Test Duration(TF—Tl): I HOUR 1 HOUR 1 HOUR I HOUR <br /> Change in Reading(RF-RI): 0 0 0 0 <br /> Pass/Fail Threshold or 0 0 0 0 <br /> Criteria: <br /> Test Result: jj ® 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 with legal requirements. <br /> Technician's Signature: Date:10-26-17 <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 />