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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(f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1.FACILITY INFORMATION <br /> Facility Name: BILL'S 76 Date of Testing: 2/27/14 <br /> Facility Address: 633 E. VICTOR RD. LODI, CA 95240 <br /> Facility Contact: BILL Phone: <br /> Date Local Agency Was Notified of Testing:2/12/14 <br /> Name of Local Agency Inspector(fpresent during testing): ARIS&WILLY <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 263373-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 I EAST 2 MIDDLE 3 WEST 4 <br /> Number, Stored Product, etc.) <br /> ® Direct Bury F1 Direct Bury <br /> Bucket Installation Type: ®Direct Bury ® Direct Bury El Contained in El Contained in <br /> E] Contained in Sump El Contained in Sump Sump Sum <br /> Bucket Diameter: 11 11 11 <br /> Bucket Depth: 14 13 1/8 13 3/4 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 0930 0930 0930 <br /> Initial Reading(RI): 13 1/8 12 1/8 12 1/2 <br /> Test End Time(TF): 1030 1030 1030 <br /> Final Reading(RF): 13 1/8 12 1/8 12-- <br /> Test Duration(TF—TI): HR HR HR <br /> Change in Reading(RF-RI): 0 0 - 1/2 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: ® Pass ❑Fair Z Pass ❑Fail ❑ Pass ®Fail ® Pass ❑Fail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> WEST TANK FILL FAILED TESTING, ELITE IV to repair& retest. <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:2-27-14 <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 />