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l <br /> SWRCB , January 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intended for rise by contractors performing annual testing of UST spill containment structures. The completed form and <br /> prI touts from tests (fcrpplicable), should be provided to the facility owner/operatorfor submittal to the local regulatory agency. <br /> 1 . FACILITY INFORMATION j <br /> Facility Name: TOKAY KWIK SERVQ F Date of Testing: 01 -3148 i <br /> Facility Address : 420 KE`I"I'LE MEN BLVD LODI CA <br /> Facility Contact: NICK Phone: 209-369-2790 <br /> Date Local Agency Was Notified of Testing :014648 j <br /> Name of Local Agency Inspector (rf present dining testing): SAN JOAQUIN CO <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 El vacuum ElOther <br /> Test Equipment Used: TAPE / H2O Equipment Resolution : <br /> i <br /> Identify Spill Bucket (By Tank 1 87 2 91 3 DIESEL 4 100 <br /> rVurnber, Stared Product etc: <br /> ® Direct Bury ® Direct Bury ® Direct Bury ® Direct Bury <br /> Bucket Installation Type : ❑ Contained in Sump ❑ Contained in Sump ❑ Contained in Contained in <br /> Sump Sum <br /> i <br /> Bucket Diameter: 11 11 11 11 <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 (R►) : 12 14 I3 13 <br /> Test End Time (TF) : 1400 1400 I400 1400 <br /> Final Reading (RF) : 12 14 13 13 <br /> Test Duration (Tr — TI): 1 HOUR I HOUR 1 HOUR I HOUR <br /> Change in Reading (Rr• - Rr) : 0 0 0 <br /> Pass/Fall Threshold or <br /> Criteria: ' <br /> Test Result: ® Pass ❑ i <br /> ❑ Fail ® Pass ❑ Fail ® Pass El ® Pass Fall <br /> Comments -- (inchrde information on repairs made prior to testing, and recommended follotiv-Irp for failed tests) <br /> OPW BUCKETS <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: Daw01 -3148 <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 />