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Spill Bucket Testing Report Form SWRCB,January 2006 <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(efaipplicable), should be provided to thefacility owner/operator far submittal to the local regulatory agency. <br /> 1.FACILITY INFORMATION <br /> Facility Name: E.F.KLUDT AND SONS Date of Testing: 4/7/16 <br /> Facility Address: 1126 E.PINE ST LODI,CA <br /> Facility Contact: STEVE Phone: <br /> Date Local Agency Was Notified of Testing:3/24/16 <br /> Name of Local Agency Inspector(ifpresent during testing): <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: NEd Stearns ❑ D.Nimmo Lyle <br /> 5250492-UT y E] Zane A.Nimmo ❑ David A. Winkler El Felix G.Ramirez <br /> 5249115-UT 5263322-UT 5263373-UT 5273934-UT <br /> Credentials': N ICC Service Tech. N SWRCB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: N 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 /> Bucket Installation Type: ®Direct Bury N Direct Bury Direct Bury ❑ Direct Bury <br /> ❑ Contained in Sump ❑Contained in Sump ❑Contained in ❑ Contained in <br /> Bucket Diameter. 12 12 Sum Sum <br /> Bucket Depth: 12 12 <br /> Wait time between applying <br /> vacuum/water and start of test: -- <br /> Test Start Time(TO.- 1330 1330 <br /> Initial Reading(R,): I I I 1 <br /> Test End Time(TF): 1430 1430 <br /> Final Reading(RF): 10 11 <br /> Test Duration(TF—Tt): IHR IHR <br /> Change in Reading(RF-R,): P 0 <br /> Pass/Fail Threshold or 1/16 <br /> Criteria: 1/16 1/16 <br /> Test Result: ❑ Pass N Fail I N Pass ❑ Fail ❑ Pass <br /> ❑Fail ❑ Pass ❑ Fail <br /> Comments— (include information on repairs made prior to testing, and recommended follow-up lbr failed tests) <br /> KEROSENE BUCKET FAILED COULD NOT LOCATE LEAK POINT. <br /> TO BE REPAIRED AND RETESTED BY Elite IV <br /> 6 <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING wflo,AaM�- <br /> I hereby certify that all the information contained in this report is true,accurate,and in full compliance with legal requirements. Foe <br /> Signature:) 6'f Date:4/7/16 <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 />