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FEB 3 9ACB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intended for use by contractors performing annual testing of UST spill contamment r urea �NTA <br /> c pleCed form and <br /> printouts from tests(af applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1.FACILITY INFORMATION <br /> Facility Name: BILLS 76 Date of Testing: 02-02-15 <br /> Facility Address: 633 E VICTOR RD LODI CA <br /> Facility Contact: RUPI Phone: 367-1795 <br /> Date Local Agency Was Notified of Testing:1-20-15 <br /> Name of Local Agency Inspector(if present during testing): JEFF WONG <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 4162 nd 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': ®ICC Service Tech. ® SWRCB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ®Hydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used: TAPE/H2O Equipment Resolution: 1/16 <br /> r=,.. <br /> Identify Spill Bucket(By Tank 1 87 2 89 3 91 4 <br /> Number, Stored Product, etc. <br /> Direct Bury Direct Bury <br /> Bucket Installation Type: ®Direct Bury ®Direct Bury ❑Contained in ❑Contained in <br /> E]Contained in Sump ❑Contained in Sump SumpSum <br /> Bucket Diameter: 11 11 11 <br /> Bucket Depth: 14 14 14 <br /> Wait time between applying _ _ - <br /> vacuum/water and start of test: <br /> Test Start Time(Tj): 1251 1251 1251 <br /> Initial Reading(Rj): 12 1/2 123/4 123/4 <br /> Test End Time(TF): 1351 1251 1251 <br /> Final Reading(RF): 12 1/2 123/4 123/4 <br /> Test Duration(TF—Tj): 1 HOUR 1 HOUR 1 HOUR <br /> Change in Reading(RF-RI): 0 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: ® Pass ❑Fail ® Pass ❑Fail 0 Pass ❑Fail ❑ Pass ❑]Fail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> ®PW BUCKETS <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: ,.i Date:02-02-15 <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 />