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SWRCB , January 2006 <br /> Spill Bucket Testing Report Form <br /> t <br /> This form is intendedfar rtse by contractor s pei forrtring annual testing of UST spill containment sb•ttctut•es. The completed form and <br /> printouts fr•onr tests (rf applicable), shoulcl be provided to the facility owner/operator for submittal to *the local regulatory agency, f <br /> 1. FACILITY INFORMATION <br /> Facility Name : TOKAY ICWIK SERVQ Date of Testing: 01 -31 -18 <br /> Facility Address : 420 KETTLE MEN BLVD LODI CA <br /> i <br /> Facility Contact: NICK Phone : 209-369-2790 <br /> Date Local Agency Was Notified of Testing :01 - 1648 <br /> Name of Local Agency Inspector (rf present during testing): SAN JOAQUIN CO F <br /> i <br /> i <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name ; AFFORDA TEST 416 2nd Street Galt, CA 95632 (209) 744-0112 .Fax : (209) 744-0116 <br /> Technician Conducting Test: ❑ Ed Sterns ❑ Zane A. Nimmo ❑ David A. Winkler Felix G . Ramirez <br /> 8141MUT 8211269-UT 5263373 -UT 5273934-UT <br /> Credentials ' : ❑ ICC Service Tech, ❑ SWRCB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used : ® Hydrostatic ❑ Vacuum ❑ Other <br /> Test Equipment Used : TAPE / H2O Equipment Resolution : <br /> Identify Spill Bucket (By Tank I WASTE OIL 2 3 4 <br /> Number Stored Product etc. <br /> ® Direct Bury ❑ Direct. Bury E] Direct Bury E] Direct Bury <br /> Bucket Installation Type: ❑ Contained in ❑ Contained in <br /> ❑ Contained in Sump ❑ Contained in Sump Sum Sum <br /> Bucket Diameter: 11 <br /> Bucket Depth: 12 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time (Tt): 1300 <br /> Initial Reading (Rt) : 12 <br /> Test End Time (Tr) : 1400 <br /> Final Reading (RF): 12 <br /> Test Duration (TF — Ti) : 1 HOUR <br /> Change in Reading (RF - Rt) : 0 1 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Resnit: ® Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail <br /> Comments - (include information on repairs made prior to testing, and recommended follow-trp•fo)•,failed tests) <br /> OPW BUCKETS <br /> i <br /> i <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 /> f <br /> Technician' s Sig nature : Date:01 -31 - 18 <br /> l <br /> State Iaws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements <br /> may be more stringent, <br /> i <br /> i <br />