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This Spill Bucket Testing Report Form -es. The conipleh I./orin and <br />firin is infendedjbr use bil contractors perlbrtning annual testing of UST spill containment structures. -egulatort agency. <br />printouts from tests (if applicable), should be provided to lhepcilh�� ownerl'operatorfbi- submittal to the local i <br />qrl"V <br />FacilityName: GEORGE KISH IDA TRUCKING Date of Testing: 11/20/2015 <br />Facility Address: 1725 ACKERMAN DR City: LODI <br />Facility Contact: KELLI Phone: 209-368-0603 <br />Date Local Agency Was Notified of Testing: Monday, August 24, 2015 <br />Name of Local Agency Inspector (if present during testing): ARIS VELOSO <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: BZ Service Station Maintenance <br />Technician Conducting Test: RHOME DESDIENS <br />0- -1 j <br />credentialsi.. CSLB Conti -actor ICC Service Tech. ❑ SWRCBTankTester Other (Spec�/,-) <br />License Number(s): 433159 <br />s carr IF 1n1rT1-1ZVVrVVQ9r1r0&- 11XJVnDX4A9r1nV <br />—Test Method Used: <br />Hydrostatic <br />❑ Vacuum <br />El Other <br />Test Equipment Used: RULER <br />Equipment Resolution: <br />1/16" <br />3 <br />4 <br />Identify Spill Bucket (8y Tank <br />I T5 - DSL 2 T6 -DSL <br />Number, Stored Product, etc.) <br />Installation Type: <br />Z Direct Bury <br />E] Contained in Sump <br />M Direct ffu-ry— <br />❑ Contained in Sump <br />El Direct Bury <br />El Contained in Sump <br />D vct BuryBucket <br />—E] Conta ned in Sump <br />Bucket Diameter: <br />11- <br />11" <br />Bucket Depth: <br />1719 <br />17" <br />Wait time between applying <br />vacuum/water and start of test: <br />5 MIN <br />5 MIN <br />Test Start Time (Ti): <br />10:00 <br />11:10 <br />Initial Reading (111): <br />16'— <br />16" <br />Test End Time (TF): <br />11:00 <br />12:10 <br />ULLI <br />Final Reading (RF): <br />16" <br />16" <br />T <br />Test Duration (TI., - Tj): <br />I HR <br />I HR <br />m <br />Change in Reading (RF - Rj): <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />0 <br />0 <br />Test Result: <br />ED Pass E] Fall <br />[D Pass E] Fail <br />El Pass [I Fail <br />Fail <br />Comments - (inchide iiffiortitation on repairs made prior to testing, and recommended ft)11oiv-tqifor ,failed 1(:;ts) <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 require nents. <br />Technician's Signature: Date: 11/20/2015 <br />State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requiremer Is may be more <br />stringent. <br />Monitoring Certification Test Report <br />4 of 4 <br />