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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(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1.FACILITY INFORMATION <br /> Facility Name: George Kishida Date of Testing: 11/17/2017 <br /> Facility Address: 1725 Acherman Dr City:Lodi <br /> Facility Contact: Phone: 209-368-0603 <br /> Date Local Agency Was Notified of Testing: Friday,October 13,2017 <br /> Name of Local Agency Inspector(if present during testing): Ceasar <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: BZ Service Station Maintenance <br /> Technician Conducting Test: Rhome Desbiens <br /> Credentials': 0 CSLB Contractor ICC Service Tech. ❑ SWRCB Tank Tester ❑Other(Spec) <br /> License Number(s): 433159 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br /> Test Equipment Used: Ruler Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By Tank 1 DSL-1 2 DSL-2 3 4 <br /> Number, Stored Product, etc.) <br /> Bucket Installation Type: ® Direct Bury ® Direct Bury ❑ Direct Bury ElDirect Bury <br /> ElContained in Sump ❑Contained in Sump ❑ Contained in Sump ❑ Contained in Sum <br /> Bucket Diameter: 11" <br /> Bucket Depth: 17 1/4" <br /> Wait time between applying <br /> vacuum/water and start of test: Smin <br /> Test Start Time(Ti): 9:55 <br /> Initial Reading(RI): 16 7/16" <br /> Test End Time(TF): 10:55 <br /> Final Reading(RF): 16 7/16" <br /> Test Duration(TF—Ti): Ihr <br /> Change in Reading(RF—RI): 0 <br /> Pass/Fail Threshold or 0 <br /> Criteria: <br /> Test Result: ® Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail <br /> Comments— (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> DSL-2 Bucket Failed. Leaking near top of bucket. Bucket will need to be replaced & retested. <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: Date: <br /> ' State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more <br /> stringent. <br /> Monitoring Certification Test Report <br /> 4 of 4 <br />