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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 complete ellbrin and <br />printouts from tests (if applicable), should be provided to the, facility ownerloperator.f6r submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: George Kishida Date of Testing: 11/17/2017 <br />Facility Address: 1725 Acherman Dr City: Lodi <br />Facility Contact: Phone: 209-368-0603 - ----- - <br />Date Local Agency Was Notified of Testing Friday, October 13, 2017 <br />Name of Local A2encv Inspector (ifDresent durinz testing): Ceasar <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: BZ ServiceStictionMaintenance---- <br />Technician Conducting Test: Rhorne Desbiens <br />Credentials': 0 CSLB Contractor M ICC Service Tech, El SW—RCf�-fai7i-k-T­e`s-te—r---0 Other Qecifv) <br />V1 <br />License Number(s): 433159 <br />3. SPILL BUCKET TESTING INFORMATION —1 <br />MT., kAtk..4 T lepA, r7l 14vAmztntir. F-1 Vno.uurn Other I <br />Test Equipment Used: Ruler Equipment Resolution: 1/16" <br />Identify Spill Bucket (By Tank <br />I DSL -1 2 DSL -2 3 4 <br />Number, Stored Product, etc.2 <br />Z Direct Bury M—Direct Bury Direct Bury Direct Bury <br />Bucket Installation Type: E] Contained in Sum El Contained in Sump El Contained in Sump _�Con�taineq in Sump 11 <br />Bucket Diameter: 11" <br />Bucket Depth: 17 1/4"J: <br />Wait time between applying <br />5min <br />vacuum/water and start of test: <br />Test Start Time (Ti): 9:55 <br />Initial Reading (111): 16 7/16" <br />Test End Time (TF): 10:55 <br />Final Reading (RF): 16 7/16" <br />Test Duration (TF - Tj): <br />1hr <br />A <br />Change in Reading (RF - Ri): <br />0 <br />Pass/Fail Threshold or <br />0 <br />Criteria: <br />Test Result: <br />®Pass Q Fail, <br />Q fass [„] Fail <br />Ej Pass f3 fail <br />0 pass Fail 1 <br />Comments - (include information on repairs made, prior to testing, and recommended follow-zipjorjailed tests) <br />DSL -2 Bucket Failed. Leaking near top of bucket. Bucket will need to be replaced & retested. <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: <br />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 />