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« t � <br />F =CENED <br />SEP 2 5 ZORCB, January 2006 <br />Spill Bucket Testing Report Form <br />ENVIRONMENTAL <br />This form is intended for use by contractors performing annual testing of UST spill contain ,�c ,� �ifVeted form and <br />printouts from tests (if applicable), should be provided to the facility owner/operator,for , u a i0 the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: BAGLEY — LODI CORP YARD I Date of Testing: 9-17-18 <br />Facility Address: 1331 S HAM LN LODI, CA 95240 <br />Facility Contact: RANDY Phone: 209-333-6830 <br />Date Local Agency Was Notified of Testing:8/23/18 <br />Name of Local Agency Inspector (f present during testing): STACY <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: AFFORDA TEST 416 2"d Street Galt, CA 95632 (209) 744-0112 Fax: (209) 744-0116 <br />Technician Conducting Test: ❑ Ed Stearns ❑ Zane A. Nimmo E David A. Winkler ❑ Felix G. Ramirez <br />8883080 -UT 8883064 -UT 8883059 -UT 8883072 -UT <br />Credentials': E ICC Service Tech. E SWRCB Tank Tester <br />3_ SPTI.T, RTICKF,T TFSTTNG INFORMATION <br />Test Method Used: E Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: TAPE / H2O <br />Equipment Resolution: 1/16 <br />Identify Spill Bucket (By Tank1 <br />A'umber, Stored Product, etc.) ] <br />87 <br />2 87 <br />I <br />3 DIESEL <br />4 <br />Bucket Installation Type: <br />E Direct Bury <br />El Contained in Sump <br />E Direct Bury <br />El Contained in Sump <br />❑ Direct Bury <br />E Contained in <br />Sump <br />❑ Direct Bury <br />E] Contained in <br />Sum <br />Bucket Diameter: <br />1 1 <br />11 <br />12X15 <br />Bucket Depth: <br />14 <br />12 <br />24 <br />Wait time between applying <br />vacuum/water and start of test: <br />- <br />- <br />Test Start Time (Ti): <br />12 <br />12 <br />12 <br />Initial Reading (RI): <br />14 <br />12 <br />23 <br />Test End Time (TF): <br />1 <br />1 <br />1 <br />Final Reading (RF): <br />14 <br />12 <br />23 <br />Test Duration (TF — TI): <br />I HOUR <br />1 HOUR <br />1 HOUR <br />Change in Reading (RF - Rj): <br />0 <br />4 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />Test Result: <br />E Pass []Fail <br />E Pass ❑ Fail <br />E Pass ❑ Fail <br />❑ Pass ❑ Fail <br />Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />ALL PASSED <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: W <br />Date:9-17-18 <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 />