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L'P'L <br /> APR 19 2016WRcB,January 2006 <br /> Spill Bucket Testing Report FormAPR <br /> r�A� � ^ <br /> This form is intended far use by contractors performing annual testing of UST spill commry f� 'Q p � gjr}pleted form and <br /> printouts from tests(f applicable), should be provided to the facility owner/operator for submit[al tat a ocaY regzdatory agency. <br /> 1.FACILITY INFORMATION <br /> Facility Name: E.F.KLUDT AND SONS <br /> Date of Testing: 4/7/16 <br /> 26 <br /> Facility Address: 1 IE 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 2"^Street Galt,CA 95632 <br /> (209)744-0112 Fax:(209)744-01]6 <br /> Technician: NEd Stearns ❑Lyle D.Nimmo ❑ Zane A.Nimmo <br /> 5250492-UT ❑ David 3 Winkler ❑ Felix G.Ramirez <br /> 5249115-UT 5263322-UT 5263373-UT 5273934-UT <br /> Credentials': N ICC Service Tech. N SWRC13 Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: N Hydrostatic ❑Vacuum ❑ Other <br /> Test Equipment Used: TAPE MEASURE Equipment Resolution: 1/16 <br /> Identify Spill Bucket(By Tank 1 20-K DIE 2 R-DYE MAIN G 3 <br /> Number, Stored Product, etc.) 4 <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: 11 11 Sump Sum <br /> Bucket Depth: 11 14 <br /> Wait time between applying <br /> vacuum/water and start of test: -- <br /> Test Start Time(Ti): 1330 1330 <br /> Initial Reading(Rt): ]0 13 <br /> Test End Time(TF): 1430 1430 <br /> Final Reading(RF): 10 13 <br /> Test Duration(TF—Ti): IHR IHR <br /> Change in Reading(RF-Rt); 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: 1/16 1/16 <br /> Test Result: 11 N Pass ❑Fail N Pass ❑Fail ❑ Pass ❑Fail <br /> F-1 ❑ 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 /> Technician's Signature e4 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 />