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Spill Bucket Testing Report Form <br />This form is intended for use by contractors performing annual testing of UST spill containment structu <br />printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to th, <br />1_ FAC11,ITV INFORMATION <br />)6 <br />M <br />Facility Name: FLAG CITY SHELL Date of Testi n E. 4-17-13 <br />Facility Address: 6437 W BANNER RD LODI CA <br />TAPE MEASURE <br />Facility Contact: Rupi Phone: <br />Date Local Agency Was Notified of Testing :2-26-15 APR ft 9 2015 <br />Name of Local Agency Inspector (rfpresent during testing): Willy <br />TiENVIRUNMENTAL <br />NC 1-V "L-URU I 4AL-RI I <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_ SPii.I, RITCKET TESTING INFORMATION <br />Test Method Used: ®Hydrostatic ❑ Vacuum ❑Other <br />Test Equipment Used: H2O & <br />TAPE MEASURE <br />Equipment Resolution: 1/16 <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />1 87 <br />2 91 <br />3 DSL <br />4 <br />Bucket Installation Type: <br />® Direct Bury <br />[:1 Contained in Sump <br />® Direct Bury <br />❑Contained in Sump <br />® Direct Bury <br />El Contained in <br />Sump <br />E] Direct Bury <br />❑ Contained in <br />Sum <br />Bucket Diameter: <br />11 <br />11 <br />11 <br />Bucket Depth: <br />12.50 <br />12.50 <br />12.50 <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 />11 <br />11 <br />11 <br />Initial Reading (RI): <br />12 <br />12 <br />11.25 <br />Test End Time (TF): <br />12 <br />12 <br />12 <br />Final Reading (RF): <br />12 <br />12 <br />11.25 <br />Test Duration (TF — TI): <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 Result: <br />® Pass ❑ Fail <br />0 Pass ❑ Fail <br />® Pass ❑ <br />Fail <br />❑ Pass ❑ Fail <br />Comments - (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />OPW <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: Tc-�—j <br />Date: 3-23-2015 <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 />