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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, for,n cruel <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 IDate 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 (rfpresent during testing): ARRIS <br />"i TTL"r!TAT TSTT,�T» . <br />Company Name: AFFORDA TEST 4162 nd Street Galt, CA 95632 (209) 744-0112 Fax: (209) 744-01-1-6 <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 />1 CPTT.T RTTr'1VVrr rrVQ'rnsrn TATT.r nXX A rVTONAT <br />— — u•aca a a v; � <br />Test Method Used: ® Hydrostatic ❑ Vacuum El Other <br />Test Equipment Used: H2O & TAPE MEASURE <br />Maw <br />Identify Spill Bucket (By Tank I RED DSL <br />Number, Stored Product, etc) <br />Bucket Installation Type: ®Direct Bury <br />❑ Contained in Sump <br />Equipment Resolution: Q/I <br />on . — <br />2 DSL 2 <br />®Direct Bury <br />❑ Contained in Sump <br />4 <br />1"p'irect Bury <br />❑Contained in <br />Sum <br />Bucket Diameter: 11 <br />11 <br />Bucket Depth: 13 <br />13 <br />Wait time between applying NA <br />vacuum/water and start of test: <br />NA <br />NA <br />Test Start Time (Ti): 9 <br />9 <br />-- <br />Initial Reading (Rj): 12 <br />12 <br />- <br />Test End Time (TF): 10 <br />10 <br />Final Reading (RF): 12 <br />12 <br />Test Duration (TF - Ti): 1 HR <br />I HR <br />Change in Reading (RF - RI): 0 <br />p <br />Pass/Fail Threshold or 1/16 <br />Criteria: <br />1/16 <br />-._. <br />Test Result: PASS " <br />;Pass ( Fail 01 Pass Q Fail <br />❑ Pass ❑ Fail_ J, <br />vsaawcuaa - Itnctuae tnjormarion 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 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 />