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SP ill Bucket Testing Report Form <br /> This form is intended for use by contractors performing annual testing of UST spill containment structures. The complet�d 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.FACILITY MORMATI6N <br /> Facility Name: LODI FOOD&LIQUOR Date of Testing: 11/19/ <br /> Facility Address: 1225 W LOCKFORD City:LODI <br /> Facility Contact: PAL Phone: 209-333-1038 <br /> DEb 19 2014 <br /> Date Local Agency Was Notified of Testing: Monday,October 20,2014 <br /> Name of Local Agency Inspector(fpresent during testing): ARIS VELOSO EW <br /> 2.TESTING CONTRACTOR INFORMATION E VI <br /> Company Name: BZ Service Sf tion Maintenance <br /> Technician Conducting Test: ALEXANDER TATE <br /> Credentials': 0 CSLB Contractor ICC Service Tech. SWRCB Tank Tester El Other(Spec) <br /> License Number(s): 433159 <br /> 3. SPILL BUCKET TESTINQ INFORMATION <br /> Test Method Used: ® Hydrostatic El vacuum ❑Other <br /> Test Equipment Used: TAPE MEASURE' Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By Tank � 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: 11" 11" 11" <br /> Bucket Depth: 11.25" 9" 9.75" <br /> Wait time between applying 5 MIN 5 MIN 5 MIN <br /> vacuum/water and start of test: <br /> Test Start Time(Tj): 9:50 9:50 9:50 <br /> Initial Reading(Ri): 11.25" 9" 9.75" <br /> Test End Time(TF): 12:50 10:50 10:50 <br /> Final Reading(RF): 11.25" 9" 9.75" <br /> Test Duration(TF—Tj): 1 IHR 1 HR 1 HR <br /> Change in Reading(RF—RI): 0 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: 0 0 0 <br /> feyj <br /> t ,<E`„y�', t*%;*hfi �✓ t .,a ..+,;�. �. '�. ;._ I Eft `� .! s., z 2 -B <br /> �, __� ._ , . � k•, '. e_ w tea � ;� a�I <br /> Comments—(include information on repairs made prior to testing and recommended follow-up for failed tests) <br /> i <br /> CERTIFICATION OF TECHNICIAN RESI ONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the information co ned in t ' eport is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature. Date: 11/19/2014 <br /> State laws and regulations do not currently requireY�esting 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 /> i <br />