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0 RECEIVED <br /> Spill Bucket Testing Report Form 4 20 <br /> FEBThis form is intended for use by contractors performing annual testing of UST spill containment structures. The complete orm and <br /> printouts from tests(f applicable), should be provided to the facility owner/operator for submittal tol re llaAdINTtor agency. <br /> 1. FACILITY INFORMATION t� <br /> Facility Name: LODI FOOD&LIQUOR Date of Testing: 11/20/2013 <br /> Facility Address: 1225 W LOCKFORD City:LODI <br /> Facility Contact: PAL Phone: 209-333-1038 <br /> Date Local Agency Was Notified of Testing: Friday,October 04,2013 <br /> Name of Local Agency Inspector(f present during testing): ARIS CACAPIT <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: BZ Service Station Maintenance <br /> Technician Conducting Test: KELVIN CRUZ <br /> Credentials': ® CSLB Contractor ®ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other(Spec) <br /> License Number(s): 433159 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ® Hydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used:TAPE MEASURE Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By Tank 1 87 2 91 3 DSL 4 <br /> Number, Stored Product, etc. <br /> Bucket Installation Type: ®Direct Bury ®Direct Bury ®Direct Bury ❑Direct Bury <br /> ❑Contained in Sump Contained in Sump Contained in Sump ❑Contained in Sum <br /> Bucket Diameter: 1199 1199 1179 <br /> Bucket Depth: 1299 1199 1099 <br /> Wait time between applying 5 MIN 5 MIN 5 MIN <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 11:04 9:55 9:55 <br /> Initial Reading(Ri): 1F9 9.75" 997 <br /> Test End Time(TF): 12:04 10:55 10:55 <br /> Final Reading(RF): 1199 9.75" 997 <br /> Test Duration(TF—Tj): 1 HR 1 HR 1 HR <br /> Change in Reading(RF—RI): 0 0 0 <br /> Pass/Fail Threshold or 0 0 0 <br /> Criteria: <br /> I'est. iesallt Pass ❑iail Pass [7j. "Z Pass <br /> Q <br /> 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: 11/20/2013 <br /> ' State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements may be more <br /> stringent. <br /> Monitoring Certification Test Report <br /> 4 of 4 <br />