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SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This.1orn7 is intended fol•use by contractors performing annual testing of UST spill containment structures. The completed forst and <br /> pr•intoerls,fi•orn tests(if applicable), should be provided to the facility owner/operator for•submittal to the local regulatog agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: TODAY KWIK SERVQ Date of Testing: 01-31-18 <br /> Facility Address: 420 KETTLE NEN BLVD LODI CA <br /> Facility Contact: NICK Phone: 209-369-2790 <br /> Date Local Agency Was Notified of'resting:01-16-18 <br /> Name of Local Agency Inspector Ofpre.sent dining testing): SAN JOAQUIN CO <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 41.6 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/H2O Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1 87 2 91 3 DIESEL a 100 <br /> Number, Stored 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 /> Bucket Diameter 11 11 11 11 <br /> Bucket Depth: 12 14 13 13 <br /> Wait time between applying <br /> va=im/water and start of test: <br /> Test Start Time(Ti): 1300 1300 1300 1300 <br /> Initial Reading(Rj): 12 1.4 13 13 <br /> Test End Time(Ti,): 1400 1400 1400 1400 <br /> Final Reading(RF): 12 14 l3 13 <br /> Test Duration(TF—T€): 1 HOUR 1 HOUR 1 HOUR I HOUR <br /> Change in Reading(Rr-.R€): 0 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: ® Pass ❑Fail ® Pass ❑ Fail ® Pass El Fail ® Pass [:]Fail <br /> Comments— (include information on repairs made prior to lesting, and r ecorrm)ierade, ,follow-up for•failed tests) <br /> QPW BUCKETS <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the information coutained in this report is true,accurate,and in full compliauce n-ith legal require€neuts. <br /> Technician's Signature: Date:01-31-18 <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 />