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' I t 0 9 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: LODI PAC PRIDE Date of Testing: 06-25-10 <br /> Facility Address: 351 N BECKMEN RD LODI CA <br /> Facility Contact: TED Phone: <br /> Date Local Agency Was Notified of Testing:06-04-10 <br /> Name of Local Agency Inspector(if present during testing): SAN JOAQUIN CO ARIS <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 5263373-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/H2O Equipment Resolution: 1/16 <br /> 7M tma ,, 4,, <br /> Identify Spill Bucket(By Tank 1 DIE 2 87 3 91 4 RED DIE <br /> Number, Stored Product, <br /> ❑ Direct Bury ❑ Direct Bury Direct Bury ❑ Direct Bury <br /> Bucket Installation Type: ® Contained in ® Contained in <br /> ® Contained in Sump ® Contained in Sump Sump Sum <br /> Bucket Diameter: 11 11 11 I 1 <br /> Bucket Depth: 13 13 13 13 <br /> Wait time between applying _ _ - - <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 900 1000 1000 900 <br /> Initial Reading(Rj): 12 12 12 12 <br /> Test End Time(TF). 1000 1100 1100 1000 <br /> Final Reading(RF): 12 12 12 12 <br /> Test Duration(TF—Tj): 1 HOUR 1 HOUR 1 HOUR 1 HOUR <br /> Change in Reading(RF-Rj): 0 0 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: E� PASS" ❑Fail 0 Pass ❑Fail IZ Pass ❑,Fait ® Pass ❑ Fail <br /> Comments— (include information on repairs made prior to testing, and recommended follow-up for failed tests) <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 <br /> may be more stringent. <br />