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I 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 (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1_ FAC111TV 1N1WnRMAT1n1%J <br />Facility Name: GEORGE KISHIDA TRUCKING Date of Testing: 11/7/2013 <br />Facility Address: 1725 ACKERMAN DR City: LODI <br />Facility Contact: KELLI Phone: 209-368-0603 <br />Date Local Agency Was Notified of Testing: Tuesday, October 08, 2013 <br />Name of Local Agency Inspector (if present during testing): ARTS CACAPIT <br />2. TESTING cnNTR A C TnR INFnu n r A Tinier <br />Company Name: BZ Service Station Maintenance <br />Technician Conducting Test: RHOME DESBIENS <br />Credentials: ® CSLB Contractor ® ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other (Spec) <br />License Number(s): 433159 <br />3_ SPILL RITCRET TFCTINC'_ 1NFnD1%4A9r1nXT <br />Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: RULER <br />Equipment Resolution: 1/16" <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc. <br />1 T5 - DSL <br />2 T6 - DSL <br />3 <br />4 <br />Bucket Installation Type: <br />® Direct Bury <br />❑ Contained in Sump <br />® Direct Bury <br />❑ Contained in Sump <br />❑ Direct Bury <br />❑ Contained in Sump <br />❑ Direct Bury <br />❑ Contained in Sum <br />Bucket Diameter: <br />I1" <br />11" <br />Bucket Depth: <br />17" <br />17" <br />Wait time between applying <br />vacuum/water and start of test: <br />5 MIN <br />5 MIN <br />Test Start Time (Tj): <br />10:13 <br />11:00 <br />Initial Reading (Rj): <br />15.75" <br />16" <br />Test End Time (TF): <br />11:13 <br />12:00 <br />Final Reading (RF): <br />15.75" <br />16" <br />Test Duration (TF — Tj): <br />1 HR <br />1 HR <br />Change in Reading (RF —Rj): <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />® <br />0 <br />Test Resulli <br />Pass ❑ Fail <br />0,, Pass <br />❑ Fail <br />❑ Pass ❑ P'aiI <br />El Pass ❑ Fail <br />%,ununencs — (mctuae znjormation on repairs made prior to testing and recommended follow-up for failed tests) <br />T6 DSL FAILING DUE TO BAD DRAIN VALVE, REPLACED, 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:��/l Date: 11/7/2013 <br />State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements maybe more <br />stringent. <br />Monitoring Certification Test Report <br />4 of 4 <br />