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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(trapplicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: E.F. KLUDT AND SONS Date of Testing: 4/6/15 <br /> Facility Address: 1126 E.PINE ST LODI ,CA — rt — alk 11I <br /> Facility Contact: STEVE Phone: 993-5220 <br /> Date Local Agency Was Notified of Testing:3/30/15 <br /> Name of Local Agency Inspector(ifpresent during testing): APR 16 2015 <br /> 2. TESTING CONTRACTOR INFORMATIONL <br /> Company Name: AFFORDA TEST 4162 n1 Street Galt,CA 95632 (209)744-01 I' W�tT(46 941aTI MI1F <br /> Technician: ®Ed Stearns ❑Lyle D.Nimmo ❑ Zane A.Nimmo ❑ David A.Winkler ❑ Felix G. Ramirez <br /> 5250492-UT 5249115-UT 5263322-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 MEASURE Equipment Resolution: 1/I6 <br /> Identify Spill Bucket (By Tank 1 KEROSENE 2 110 OCT 3 4 <br /> Number, Stored Product, etc. <br /> Direct Bury Lj Direct Bury <br /> Bucket Installation Type: ®Direct Bury ®Direct Bury ❑Contained in El Contained in <br /> ❑Contained in Sump ❑Contained in Sump SumpSum <br /> Bucket Diameter: 12 12 <br /> Bucket Depth: 12 12 <br /> Wait time between applying -- <br /> vacuum/water and start of test: <br /> Test Start Time(T,): 1300 1300 <br /> Initial Reading(Rj): I I 11 <br /> Test End Time(TF): 1400 1400 <br /> Final Reading(RF): 11 11 <br /> Test Duration(TF—Ti): IHR IHR <br /> Change in Reading(RF-Rj): 0 0 <br /> Pass/Fail Threshold or 1/16 1/16 1/16 <br /> Criteria: <br /> Test Result: ® Pass E]Fail ® Pass [I Fail El Pass ❑Fail El Pass [,] Fail <br /> Comments (include information on repairs made prior to testing and recommendedfollow-upforfailed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> 1 hereby certify that all the information contained in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature:) _,a'"`-' Date:4/6/15 <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 />