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1 0 0 <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 />d- Ti`S7 TXTV1'%1D T*X A rrlrn <br />Facility Namely GEORGE KISHIDA TRUCKING Date of Testing: 11/6/2014 <br />Facility Address: 1725 ACKERMAN DR City: LODI <br />Facility Contact: KELLI I Phone: 209-368-0603 <br />Date Local Agency Was Notified of Testing: Tuesday, September 16, 2014 <br />Name of Local Agency Inspector (tfpresent during testing): ARIS VELOSO <br />7'rrc'rrNr_r'nV9r12ArTn12iN1PnRMATTnN <br />Company Name: BZ Service Station Maintenance <br />Technician Conducting Test: RHOME DESBIENS <br />Credentials': E CSLB Contractor ICC Service Tech, SWRCB Tank Tester ❑ Other (Spec) <br />License Number(s): 433159 <br />1_ RPTI,T. RIT("KFT TFSTING INFORMATION <br />Test Method Used: _ <br />® Hydrostatic <br />❑ Vacuum <br />ther <br />Test Equipment Used: RULER <br />Equipment Resolution: <br />1/16" <br />3 <br />4 <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />1 T5 - DSL 2 T6 - DSL <br />Bucket Installation Type: <br />® Direct Bury <br />❑ Contained in Sum <br />® Direct Bury <br />❑ Contained in Sump <br />❑ Direct Bury <br />Contained in Sum <br />❑ Direct Bury <br />❑ Contained in Sum <br />Bucket Diameter: <br />11" <br />11" <br />Bucket Depth: <br />17" <br />17" <br />Wait time between applying <br />vacuum/water and start of test: <br />5 MIN 5 MIN <br />Test Start Time (Ti): <br />10:30 <br />11:00 <br />DEC 0 <br />201 <br />Initial Reading (R,): <br />16" <br />16.5" <br />Test End Time (TF): <br />11:30 <br />12:00 <br />ENVIRONMEN <br />X HEALTH <br />Final Reading (RF): <br />16" <br />16.5" <br />DEPARTMENT <br />Test Duration (TF — Ti): <br />1 HR <br />1 HR <br />Change in Reading (RF—RI): <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />0 <br />0 <br />Test Result: <br />Pass ❑ Fail <br />Z , Pass ❑ Fail <br />❑ Pass ❑ rail <br />[3 Pass Q Fall <br />Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />DSL -2 FAILING, LEAKING THROUGH CAP, USED TEST CAP, RETESTED & PASSED <br />DSL -I FAILING, LOOSE NIPPLE, REMOVED, DOPPED, RETESTED & PASSED <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: 11/6/2014 <br />1 State laws and regulations do not currently require testing 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 />