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v <br />11 <br />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 (if 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: 6-25-2012 <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 (fpresent during testing): ARRIS <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 />i CUTT 7. RTTI"IV rr rrVQ'TTATJ- 1r1lTW1-Vn1tX ♦ TTON T <br />Test Method Used: <br />® Hydrostatic <br />❑ Vacuum <br />0 Other <br />Test Equipment Used: H2O & TAPE MEASURE <br />7"M W1W -- <br />-- -- <br />Equipment Resolution: <br />1/16 <br />Identify Spill Bucket (By Tank <br />I DSL <br />2 91 <br />.111 , � 2-=I, I UA . a <br />3 87 <br />11 , I'll "l-,""'. --, - -.] <br />4 <br />Number, Stored Product, etc.) <br />�A-bl p — _ <br />Bucket Installation Type: <br />® Direct Bury <br />❑ Contained in Sump <br />® Direct Bury <br />Contained in Sump <br />Direct Bury <br />❑ Contained in <br />Direct Bury <br />❑ Contained in <br />Sump <br />Sum <br />Bucket Diameter: <br />t t <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 (T,): <br />9 <br />9 <br />9 <br />Initial Reading (R,): <br />12 <br />12 <br />12.50 <br />Test End Time (TF): <br />10 <br />10 <br />10 <br />Final Reading (RF): <br />5 <br />12 <br />12.50 <br />Test Duration (TF – T,): <br />1 HR <br />1 HR <br />1 HR <br />Change in Reading (RF- R,): <br />0 <br />O <br />Pass/Fail Threshold or <br />Criteria: <br />I/16 <br />1 /16 <br />1/16 <br />Test Result: <br />At#ss <br />Pass ❑ Fall <br />❑ Pass ❑ Fail <br />vuiiucuw — itnctuaer orma4!on on repairs made pri o testing and recommended <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 />t <br />Technician's Signature: T&-Ij <br />Date 6-25-2012 <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 />