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l <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 for•nr and <br /> printotits•fi•ow tests fapplicable), should be provided to the facility owner/operatorsfor submittal to the local regulatory agency. <br /> 1 . FACILITY INFORMATION <br /> Facility Name : TOKAY KWIK SERVQ Date of Testing : O1m31 - 18 <br /> Facility Address : 420 KETTLE MEN BLVD LODI CA <br /> Facility Contact: NICK Phone: 209-369-2790 <br /> Date Local Agency Was Notified of Testing :014648 <br /> Name of Local Agency Inspector (f present during testing) : SAN JOAQUIN CO <br /> r <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2111 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 1 87 2 91 3 DIESEL, 4 100 j <br /> Number, Stored Product, etc. <br /> Direct Bury ® Direct Bury 0 Direct Bury ® Direct Bury <br /> Bucket Installation Type : F1 Contained in X Contained in <br /> ❑ Contained in Sump ❑ Contained in Sump Sump Sum <br /> Bucket Diameter: 11 I 1 11 f 1 <br /> Bucket Depth ; 12 14 13 13 <br /> Wait time between applying <br /> vacuum/water and start of test : <br /> Test Start Time (TI) : 1300 1300 1300 1300 <br /> Initial Reading (Ri) : 12 14 13 13 <br /> Test End Time (TF) : 1400 1400 1400 1400 <br /> Final Reading (RF): 12 14 13 13 <br /> Test Duration (TF — Tj): 1 HOUR I HOUR I HOUR I HOUR <br /> Change in Reading (RF - RI) : 0 0 0 i <br /> Pass/Fall Threshold or _ <br /> Criteria* - 3 <br /> Test Result: ® Pass ElFail ® Pass [EEII Fail ® Pass E] Fail ® Pass ElFail <br /> Comments - (inchide infor•niation on repairs made prior to testing, and recommended follow-rip for failed tests) <br /> QPW BUCKETS <br /> CERTIFICATION OF TECIINICIAN RESPONSIBLE FOR CONDUCTING THIS TES'T'ING <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: er Date :01 -3148 <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 />