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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 />FACTLITV TNFORMATInN <br />Facility Name: LODI CORP YARD Date of Testing: 09-12-17 <br />Facility Address: 1331 S HAM LANE LODI CA 95240 <br />Facility Contact: RANDY Phone: 209-335-6830 <br />Date Local Agency Was Notified of Testing: 08-25-17 <br />Name of Local Agency Inspector (fpresent 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 Conducting Test: ❑Ed Stearns ❑ Zane A. Nimmo ❑ David A. Winkler ® Felix G. Ramirez <br />814188 -UT 8211269 -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 / H2O <br />Equipment Resolution: <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc. <br />1 87 <br />2 87S <br />3 DIESEL <br />4 <br />Bucket Installation Type: <br />® Direct Bury <br />❑ Contained in Sump <br />® Direct Bury <br />❑ Contained in Sump <br />❑ Direct Bury <br />® Contained in <br />Sump <br />❑ Direct Bury <br />❑ Contained in <br />Sum <br />Bucket Diameter: <br />11 <br />12 X 15 <br />Bucket Depth: <br />14 <br />24 <br />Wait time between applying <br />vacuum/water and start of test: <br />- <br />Test Start Time (Ti): <br />1300 <br />1300 <br />Initial Reading (RI): <br />14 <br />23 <br />Test End Time (TF): <br />1400 <br />1400 <br />Final Reading (RF): <br />14 <br />23 <br />Test Duration (TF — Ti): <br />1 HOUR <br />1 HOUR <br />Change in Reading (RF - Rj): <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />- <br />Closed <br />- <br />Test Result: <br />® Pass ❑ Fail <br />❑ Pass ❑ Fail <br />® Pass ❑ Fail <br />❑ Pass ❑ Fail <br />Comments — (include information on repairs made prior to testing, and recommended ollow-up forfaited tests) <br />87 S Tank bucket closed — not tested, inspector Stacy W/SJC on site <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: <br />Date:09-12-17 <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 />