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' <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 farm 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: E.F. KLUDT AND SONS Date of Testing: 4/6/15 <br /> Facility Address: 1126E PINE ST LODI,CA ar <br /> Facility Contact: STEVE Phone: <br /> Date Local Agency Was Notified of Testing:3/30/15 <br /> Name of Local Agency Inspector(fpresent during testing): APR 16 2015 <br /> 2. TESTING CONTRACTOR INFORMATION ENVIRONMENTAL <br /> Company Name: AFFORDA TEST 416 2nd Street Galt,CA 95632 (2 09)744-0112 Fax:(209)744-0116 <br /> Technician: EEd Stearns ❑Lyle D.Nimmo ❑ Zane A.Nimmo ❑ David A.Winkler <br /> [I Felix G. trez <br /> 5250492-UT 5249115-UT 5263322-UT 5263373-UT 5273934-UT <br /> Credentials': E ICC Service Tech. E SWRCB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ® Hydrostatic ❑ Vacuum 0 Other <br /> Test Equipment Used: TAPE MEASURE Equipment Resolution: 1/16 <br /> Identify Spill Bucket(By Tank 1 20-K DIE 2 R-DYE MAIN 3 R-DYE SYPHON 4 <br /> Number, Stored Product, etc. <br /> ® Direct Bury E Direct Bu Direct Buty Direct Bury <br /> Bucket Installation Type: Bury E] Contained in <br /> E]Contained in Sump E] Contained in Sump ❑Contained in <br /> Sum Sum <br /> Bucket Diameter: I I 11 11 <br /> Bucket Depth: 11 14 11 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Tt): 1300 1300 1300 <br /> Initial Reading(Ri): 10 13 10 <br /> Test End Time(TF): 1400 1400 1400 <br /> Final Reading(RF): 10 1300 8 <br /> Test Duration(TF—T): 1 FIR IHR IHR <br /> Change in Reading(RF-R,): 0 0 2 <br /> Pass/Fail Threshold or 1/16 1/16 1/16 <br /> Criteria: <br /> Test Result: E Pass ❑Fail E .Pass ❑ Fail ❑ Pass E Fail ❑ Pass ❑Fail <br /> Comments— (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> RED DIESEL SYPHON TANK EAST FAILED . MOVED DROP TUBE IN TO MAIN <br /> MAIN RED DYE TANK OK BY INSPECTOR <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'sSignature:l C-( ':r.'° -: Date:4/6/I5 <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 />