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SWRCB, January 2006 <br />Spill Bucket Testing Report Form MAR 16 2016 <br />This form is intended for use by contractors performing annual testing of UST spill containment structures The,compl' f rm and <br />printouts from tests (if applicable), should be provided to the facility owner/operator for submit„1ta t 6J >) cy. <br />1. FACILITY INFORMATION <br />Facility Name: FLAG CITY SHELL Date of Testing: 3-8-2016 <br />Facility Address: 6437 W BANNER RD LODI CA <br />Facility Contact: Rupi Padda Phone: 334-3214 <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (if present during aris <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: AFFORDA TEST 416 2"d 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 />II Credentials: ® ICC Service Tech. ® SWRCB Tank Tester <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: H2O & TAPE MEASURE <br />Equipment Resolution: 1/16 <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc. <br />1 87 2 91 <br />3 DSL <br />4 <br />Bucket Installation Type: <br />® Direct Bury ® Direct Bury <br />El Contained in Sump El Contained in Sump <br />® Direct Bury <br />El Contained in <br />Sump <br />❑ Direct Bury <br />E] Contained in <br />Sum <br />Bucket Diameter: <br />11 11 <br />11 <br />Bucket Depth: <br />12.50 12.50 <br />12.50 <br />Wait time between applying <br />vacuum/water and start of test: <br />NA NA <br />NA <br />NA <br />Test Start Time (Ti): <br />11 1 I <br />11 <br />Initial Reading (Ri): <br />12 12 <br />11.25 <br />Test End Time (TF): <br />12 12 <br />12 <br />Final Reading (RF): <br />12 12 <br />11.25 <br />Test Duration (TF — TI): <br />I HR I HR <br />1 HR <br />Change in Reading (RF - Rj): <br />0 0 <br />O <br />Pass/Fail Threshold or <br />Criteria: <br />1/16 1/16 <br />1/16 <br />Test Result: <br />® Pass ❑ Fail ® Pass ❑ Fail <br />Z Pass ❑ Fail <br />❑ Pass ❑ Fail <br />Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />®PW <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: 3-08-2016 <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 />