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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(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 <br /> Facility Address: 1126 E PINE ST LODI,CA Date of Testing: 4/7/16 <br /> Facility Contact: STEVE <br /> Phone: <br /> Date Local Agency Was Notified of Testing:3/24/16 <br /> Name of Local Agency Inspector(f present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2nd Street Galt,CA 95632 <br /> (209)744-0112 Fax:(209)744-0116 <br /> Technician: ®Ed Stearns ❑ D.Nimmo Lyle <br /> 5250492-UT y El Zane A.Nimmo El 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 <br /> Equipment Resolution: 1/16 <br /> Identify Spill Bucket(By Tank 1 20-K DIE 2 R-DYE MAIN 3 <br /> Number, Stored Product, etc. 4 <br /> Bucket Installation Type: ® Direct Bury ®Direct Bury Direct Bury Direct Bury <br /> ❑ Contained in Sump ❑Contained in Sump ❑ Contained in ❑Contained in <br /> Bucket Diameter: 11 11 Sum Sum <br /> Bucket Depth: 11 14 <br /> Wait time between applying <br /> vacuum/water and start of test: -- -- <br /> Test Start Time(T,): 1330 1330 <br /> Initial Reading(Rj): 10 13 <br /> Test End Time(TF): 1430 1430 <br /> Final Reading(RF): 10 <br /> 13 <br /> Test Duration(TF—Tj): I HR IHR <br /> Change in Reading(RF-Ri): 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: 1/16 1/16 <br /> Test Result: ® Pass ❑Fail ®Pass ❑Fail ❑ Pass <br /> ❑Fail ❑ pass ❑ Fail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> I hereby certify that all the information contained in this report is true,accurate,and in full compliance with l <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> egal rE(tuiremeats. <br /> Technician's Signature:) 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 />