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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. FACILITY INFORMATION <br />Facility Name: FLAME LIQUOR - MINI MARTDate of Testing: NOV 8, 2007 <br />Facility Address: 1301 W. KETTLEMAN LANE, LODI, CA 95242 <br />Facility Contact: PETE GRAFFIGNA <br />Phone: 209-334-3233 <br />Date Local Agency Was Notified of Testing: OCT 29, 2007 <br />Name of Local Agency Inspector (rf present during testing): GARRETT BACKUS <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: TANK-TEK ENVIRONMENTAL CORPORATION <br />Technician Conducting Test: ROB NEIMEYER <br />Credentials': ® CSLB Contractor ❑ ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other (Spec) <br />License Number(s): 803705 <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other (Spec) <br />Test Equipment Used: <br />Equipment Resolution: <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />I <br />REGULAR <br />2 <br />SUPER <br />3 <br />DIESEL <br />4 <br />Bucket Installation Type: <br />® Direct Bury <br />❑ Contained in Sump <br />N Direct Bury <br />❑ Contained in Sump <br />® Direct Bury <br />❑ Contained in Sump <br />❑ Direct Bury <br />❑Contained in Sump <br />Bucket Diameter: <br />10.50" <br />10.50" <br />10.50" <br />Bucket Depth: <br />13.00" <br />13.00" <br />13.00" <br />Wait time between applying <br />vacuum/water and start of test: <br />0 <br />0 <br />0 <br />Test Start Time (TI): <br />9:15 AM <br />9:15 AM <br />9:15 AM <br />Initial Reading (RI): <br />13.00" <br />13.00" <br />13.00" <br />Test End Time (TF): <br />10:15 AM <br />10:15 AM <br />10:15 AM <br />Final Reading (RF): <br />13.00" <br />13.00" <br />13.00" <br />Test Duration (TF — TI): <br />1 HOUR <br />1 HOUR <br />1 HOUR <br />Change in Reading (RF - RI): <br />0 <br />0 <br />0 <br />Pass/Fail Threshold or Criteria: <br />Test Result: <br />E� Pass ❑ Fail <br />®-Pass ❑ Fail <br />Z Pass [I 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: �� :_-_ �- Date: NOV 8, 2007 <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 />