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a w <br />6 0 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 (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1 IRA f TT .TTV INFORMATION <br />Facility Name: LODI FOOD AND LIQUOR Date of Testing: 11-23-09 <br />Facility Address: 1225 WEST LOCKFORD STREET LODI CALIFORNIA 95240 <br />Facility Contact: PAUL Phone: 209-712-4148 <br />Date Local Agency Was Notified of Testing :10-12-09 <br />Name of Local Agency Inspector (if present during testing): SAN JOAQUIN CO <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: AFFORDA TEST 4162 "d Street Galt, CA 95632 (209) 744-0112 Fax: (209) 744-0116 <br />Technician Conducting Test: ❑ Lyle D. Nimmo ❑ Zane A. Nimmo ❑ David A. Winkler ® Felix G. Ramirez <br />5249115 -UT 5263322 -UT 5263373 -UT 5273934 -UT <br />Credentials: Z ICC Service TecK. ® SWRCB Tank Tester <br />3_ RPTT.T, RTIC.KFT TESTING INFORMATION <br />Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: TAPE H2O <br />Equipment Resolution: 1/16 <br />1 87 <br />2 91 <br />3 DIE <br />4 <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />Bucket Installation Type:F-1Contained <br />® Direct Bury <br />❑Contained in Sump <br />® Direct Bury <br />❑Contained in Sump <br />® Direct Bury <br />in <br />Sump <br />❑ Direct Bury <br />F] Contained in <br />Sum <br />Bucket Diameter: <br />1 1 <br />1 I <br />1 1 <br />Bucket Depth: <br />13 <br />13 <br />12 <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (Tj): <br />1200 <br />1100 <br />1100 <br />Initial Reading (Ri): <br />13 <br />12 <br />11 <br />Test End Time (TF): <br />1300 <br />1200 <br />1200 <br />Final Reading (RF): <br />13 <br />12 <br />11 <br />Test Duration (TF — Ti): <br />1 HOUR <br />I HOUR <br />1 HOUR <br />Change in Reading (RF - Ri): <br />0 <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />0 <br />0 <br />0 <br />0 <br />Test Result: I <br />® Pass ❑,Fail <br />Z Pass ❑ Fail <br />I 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: J~ �� Date: 11/23/09 <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 />