Laserfiche WebLink
0 0 <br />ED <br />January 2006 <br />Spill Bucket Testing Report Form JL 2 9 20% <br />This form is intended for use by contractors performing annul testing of UST spial containment structures. The completed form and <br />Printouts from tests (if applicable), should be provided to the facility owner/operator for submittal <br />1. FACILITY INFORMATION E)EFARTMENT <br />Facility Name: LODI PAC PRIDE . I Date of Testing: 6-30-14 <br />Facility Address: 351 N BECKMAN LODI CA <br />Facility Contact: TED Phone: <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (if present during testing): ARIS <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 />I Credentials': ® ICC Service Tech. ® SWRCB Tank Tester n <br />41161 ;a 1 •l 10 .1111 N now I X-11 I Ikz Lei 1iz1'0) 9a F.% I CQZI <br />Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: H2O & <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc) <br />TAPE MEASURE <br />1 DSL 2 91 <br />Equipment Resolution: 1/16 <br />3 87 4 <br />Bucket Installation Te: <br />®Direct Bury <br />El Contained in Sump <br />®Direct Bury <br />El Contained in Sump <br />®Direct Bury <br />❑Contained in <br />Direct Bury <br />El Contained inSump Sum <br />Bucket Diameter: <br />11 <br />11 <br />11 <br />Bucket Depth: <br />13 <br />13 <br />13 <br />Wait time between applying <br />vacuum/water and start of test: <br />NA <br />NA <br />NA <br />NA <br />Test Start Time (TI): <br />9 <br />9 <br />9 <br />Initial Reading (RI): <br />12 <br />12 <br />12.75 <br />Test End Time (TF): <br />10 <br />10 <br />10 <br />Final Reading (RF): <br />12 <br />12 <br />12.75 <br />Test Duration (TF — Tj): <br />1 HR <br />1 HR <br />1 HR <br />Change in Reading (RF - Rj): <br />0 <br />0 <br />O <br />Pass/Fail Threshold or <br />Criteria: <br />1/16 <br />1/16 <br />1/16 <br />Test R ?It: <br />Pass ❑Fail <br />Pass ❑ Fail <br />Pass ❑ Fail <br />❑ 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: <br />Date: 6-30-14 <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 />