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RErSEIVED <br /> JUN 2 7 2014 SWRCB,January 2006 <br /> Spill Bucket Testing RepA81MENTAL HEALTH <br /> This form is intended for use by contractors performing annual testing of UST spill cor�(fMFts. The completed form and <br /> printouts from tests(if applicable),should be provided to the facility owner/operator;r``su mt ta�,�-to``tAhe Notal regulatory agency. <br /> 1.FACILITY INFORMATION <br /> Facility Name: E.F.KLUDT&SONS Date of Testing: 4/1/2014 <br /> Facility Address: 1126 E.PINE ST. LODI,CA 95240 <br /> Facility Contact: STEVE Phone: 209-368-0634 <br /> Date Local Agency Was Notified of Testing:3/5/2014 <br /> Name of Local Agency Inspector(ifpresent during testing): JEFF WONG <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2nd Street Galt,CA 95632 (209)744-0112 Fax:(209)744-0116 <br /> Technician Conducting Test: ❑Lyle D.Nimmo ® Zane A.Nimmo ❑ David A.Winkler ❑ Felix G.Ramirez <br /> 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,H2O Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By Tank 1 KEROSENE 2 110 OCTANE 3 4 <br /> Number, Stored Product, etc. <br /> ®Direct Bury ®Direct Bury <br /> El Direct Bury ❑Direct Bury <br /> Bucket Installation Type: ElContained in Sump ElContained in Sump ❑Contained in El Contained in <br /> Sump Sum <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(Tr): 1325 1325 <br /> Initial Reading(Rt): 11-- 11-- <br /> Test End Time(TF): 1425 1425 <br /> Final Reading(Rv): 11-- 11-- <br /> Test Duration(TF—Tj): HR HR <br /> Change in Reading(RF-Rj): 0 0 <br /> Pass/Fail Threshold or <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 /> 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 /> —W <br /> Technician's Signature:_ 6 — Date: 4-1-14 <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 />