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6 6 <br />b 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 front tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />l Facility Name: LODI FOOD & LIQUOR Date of Testing: 11/23/10 <br />Facility Address: 1225 W. LOCKEFORD ST. LODI, CA 95240 <br />Facility Contact: PAUL Phone: <br />Date Local Agency Was Notified of Testing :9/15/10 <br />Name of Local Agency Inspector (rf present during testing): ARIS CACAPIT - II <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: AFFORDA TEST 4162 nd Street Galt, CA 95632 (209) 744-0112 Fax: (209) 744-01 16 <br />F-1LyleD. Nimmo ® Zane A. Nimmo [I David A. Winkler ❑ Felix G, Ramirez <br />Technician Conducting Test: 5249115 -UT 5263322 -UT 5263373 -UT 5273934 -UT <br />Credentials': ® ICC Service Tech. ® SWRCB Tank Tester <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used TAPE MEASURE, H2O Equipment Resolution: 1/16" <br />Identify Spill Bucket (By Tank <br />iVumber, Stored Product, etc.) <br />1 87 <br />2 3 91 <br />4 DIESEL <br />Bucket Installation Type: <br />yp <br />_ <br />Bucket Diameter: <br />® Direct Bury <br />E] Contained in Sump <br />1 1 <br />® Direct Bury <br />❑Direct Bury <br />❑ Contained in Sump F-1 Contained in <br />Sum <br />1 1 <br />® Direct Bury <br />El Contained in <br />Sum <br />1 1 <br />Bucket Depth: <br />12 <br />11 <br />10 <br />if Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (Tj): <br />1 130 <br />1 130 <br />1210 <br />Initial Reading (Rj): <br />10 1/2 <br />9 1/2 <br />8 1/2 <br />Test End Time (TF): <br />1230 <br />1230 <br />1310 <br />Final Reading (RF): <br />10 1/2 <br />9 1/2 <br />8 1/2 <br />"Fest Duration (TF — Ti): <br />HR <br />HR <br />HR <br />Change in Reading (RF- Rj): <br />0 <br />0 <br />0 <br />�I Pass/Fail Threshold or <br />Criteria: <br />Test Result: <br />- <br />0 Pass ❑-Fail <br />-- -- <br />❑ Pass ❑ Fail I Z Pass ❑ Fail I <br />_ <br />❑ Pass ❑ Fail <br />Comments —(include information on repairs made prior to testing, and recommended follow-ul) 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 />'t'echnician's Signature: ���-- <br />Date: 11/23/10 <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 />