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r <br />�J <br />Spill Bucket Testing Report Form <br />SWRCB, January 2006 <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 MART I Date of Testing: OCT 31, 2006 <br />Facility Address: 1301 W. KETTLEMAN LANE, LODI, CA 95242 <br />Facility Contact: PETE GRAFFIGNA I Phone: 209-334-3233 <br />Date Local Agency Was Notified of Testing: OCT 12, 2006 <br />Name of Local Agency Inspector (f present during testing): <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: Equipment Resolution: <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />Bucket Installation Type: <br />1 <br />REGULAR <br />® Direct Bury <br />❑ Contained in Sump <br />2 3 <br />SUPER DIESEL <br />® Direct Bury ® Direct Bury <br />❑ Contained in Sump ❑ Contained in Sump <br />4 <br />❑ Direct Bury <br />❑ Contained in Sump <br />Bucket Diameter: <br />10.50" <br />10.50" 10.50" <br />Bucket Depth: <br />9.00" <br />9.25" 9.50" <br />Wait time between applying <br />vacuum/water and start of test: <br />0 <br />0 0 <br />Test Start Time (TI): <br />10:00 AM <br />10:00 AM 10:00 AM <br />Initial Reading (RI): <br />9.00" <br />9.25" 9.50" <br />Test End Time (TF): <br />10:30 AM <br />10:30 AM 10:30 AM <br />Final Reading (RF): <br />9.00" <br />9.25" 9.50" <br />Test Duration (TF — TI): <br />30 MIN <br />30 MIN 30 MIN <br />Change in Reading (RF - RI): <br />1 0 <br />0 0 <br />Pass/Fail Threshold or Criteria: <br />Test Result: <br />Pass ❑ Fail' <br />® Pass ❑ Fail Z Pass ❑ 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: OCT 31, 2006 <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 />