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SWRCB , January 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intended for use by contractors per forming annual testing of UST spill containment slituctures. The completed form and <br /> printouts from tests (tf applicable), should be provided to the facility owner/operator for subrriittal to the local regulatory agency. <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 /> Facility Contact : NICK Phone: 209-369-2790 <br /> Date Local Agency Was Notified of Testing 6014648 <br /> Name of Local Agency Inspector (ff present during testing) : SAN JOAQUIN CO 1 <br /> Z <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: ❑ Ed Sterns ❑ Zane A. Nimmo ❑ David A. Winkler ® Felix G . Ramirez <br /> 814188-UT 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 / I.120 Equipment Resolution: <br /> Identify Spill Bucket (By Tank 1 WASTE OIL 2 3 4 <br /> Mumbei, Stored Product etc. <br /> ® Direct Bury El Direct Bury <br /> ❑ Direct Bury El Direct Bury <br /> Bucket Installation Type: ❑ Contained in ❑ Contained in <br /> ❑ Contained in Sump ❑ Contained in Sump Sum Sum <br /> Bucket Diameter: I 1 <br /> Bucket Depth: 12 <br /> Wait time between applying _ <br /> vacuunt/water and start of test: <br /> Test Start Time (Ti) : 1300 <br /> Initial Reading (Rr) : 12 <br /> Test End Time (Tr) : 1400 <br /> Final Reading (RF) : 12 <br /> Test Duration (TF — Ti) : 1 HOUR <br /> Change in Reading (RF - Ri) : 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: 0 Pass ❑ Fail ❑ Pass ❑ Fall ❑ Pass ❑ Fail ❑ Pass ❑ Fail <br /> Comments - (inchide information on repairs made prior to testing, and recommended follow-up for ,failed tests) <br /> QPw BUCKETS <br /> 3 <br /> i <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 /> Technician' s Si nature: Date: 01 -31 - 18 <br /> g , <br /> i 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 />� E <br /> E <br />