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i <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 : SHORT STOP 76 Date of Testing : 94748 <br /> Facility Address : 20 W TURNER RD LODI CA <br /> Facility Contact: Phone : 209-369-3697 <br /> Date Local Agency Was Notified of Testing: 8/23/18 <br /> Name of Local Agency Inspector (ifpresent during testing) : STACY <br /> I 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 Stearns ❑ Zane A. Nimmo ® David A. Winkler ❑ Felix G. Ramirez <br /> 8883080-UT 8883064-UT 8883059-UT 8883072-UT <br /> Credentials ' : ® ICC Service Tech. ® SWRCB Tank Tester <br /> I SPILL BUCKET TESTING INFORMATION <br /> Test Method Used : ® Hydrostatic ❑ Vacuum ❑ Other <br /> Test Equipment Used : TAPE / H2O Equipment Resolution : 1 / 16 <br /> Identify Spill Bucket (By Tank 1 87 2 91 3 DIESEL 4 <br /> Number, Stored Product, etc. <br /> Bucket Installation Type : ® Direct Bury ® Direct Bury <br /> ® Direct Bury ❑ Direct Bury <br /> Yp ❑ El Contained in ❑ Contained in Contained in Sump ❑ Contained in Sump Sump Sum <br /> Bucket Diameter: 11 11 11 <br /> Bucket Depth : 13 13 16 <br /> Wait time between applying _ <br /> vacuum/water and start of test: - <br /> Test Start Time (Ti) : 10 10 10 <br /> Initial Reading (RI) : 12 12 15 <br /> Test End Time (TF) : I 1 11 11 <br /> Final Reading (RF) : 12 12 15 <br /> Test Duration (TF — TI) : I HOUR 1 HOUR 1 HOUR <br /> Change in Reading (RF - RI) : 0 0 0 <br /> Pass/Fail Threshold or _ <br /> Criteria: - - <br /> Test Result. ® Pass ❑ Fail ® Pass ❑ Fail ® Pass ❑ Fail ❑ Pass <br /> ❑ 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 : W Date : 09-2544 <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 />