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s +r <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 (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: FLAG CITY SHELL Date of Testing: 4-17-13 <br />Facility Address: 6437 W BANNER RD LODI CA <br />Facility Contact: Phone: <br />Date Local Agency Was Notified of Testing A-1-13 <br />Y Name of Local Agency Inspector (if present during testing): GARRET I <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: AFFORDA TEST 4162 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 />I Credentials': ® ICC Service Tech. ® SWRCB Tank Tester 11 <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 />_,r. <br />Identify Spill Bucket (By Tank 1 87 2 91 <br />3 DSL 4 <br />Number, Stored Product, etc. <br />® Direct Bury ® Direct Bury <br />® Direct Bury <br />❑ Direct Bury <br />Bucket Installation Type: <br />El Contained in Sump E] Contained in Sump <br />El Contained in <br />❑ Contained in <br />Sump <br />Sum <br />Bucket Diameter: <br />11 I 1 <br />11 <br />Bucket Depth: <br />12.50 12.50 <br />12.50 <br />Wait time between applying <br />NA NA <br />NA <br />NA <br />vacuum/water and start of test: <br />Test Start Time (Ti): <br />9 9 <br />9 <br />Initial Reading (Ri): <br />12 12 <br />11.50 <br />Test End Time (TF): <br />10 10 <br />10 <br />Final Reading (RF): <br />12 12 <br />11.50 <br />Test Duration (TF — TI): <br />1 HR 1 HR <br />1 HR <br />Change in Reading (RF - RI): <br />0 0 <br />O <br />Pass/Fail Threshold or <br />1/16 1/16 <br />1/16 <br />Criteria: <br />Test Result; <br />® Pass ❑ Fail I ® Pass '❑ Fafl <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 />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: 4-17-13 <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 />