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SWRCB, January 2006 <br />Spill Bucket Testing geport Form <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: KISHIDA TRUCKING Date of Testing: 11/10/10 <br />Facility Address: 1725 ACKERMAN DR. LODI, CA 95240 _ <br />Facility Contact KELLY Phone: <br />Date Local Agency Was Notified of Testing :11/1/10 <br />Name of Local Agency Inspector (f present during testing): ARIS CACAPIT <br />2. TESTING CONTRACT <br />Company Name: AFFORDA TEST 4162 nd Street Galt, d, <br />Technician Conducting Test: ❑ Lyle D. Nimmo ® Zane A. f <br />5249115 -UT 526332, <br />Credentials: ® ICC Service Tech. ® SWRCB Tank Tester <br />Test Method Used: <br />3. SPILL BUCKET TESA <br />® Hydrostatic ❑ Vacuur' <br />Test Equipment Used: TAPE MEASURE, H2O <br />Identify Spill Bucket (By Tank 1 NORTH DIESEL 2 BOUT <br />Number, Stored Product, etc. <br />® Direct Bury ® Direct!. <br />Bucket Installation Type: ❑ Contained in Sump ❑ Contain <br />Bucket Diameter: 11 11 <br />Bucket Depth: 17 1/2 17 1 /2 <br />Wait time between applying <br />vacuum/water and start of test: <br />0930 <br />16 1/2 <br />1030 <br />16 1/2 <br />0930 <br />Test Start Time (Tj): <br />16 1/2 <br />Initial Reading (Rj): <br />1030 <br />Test End Time (TF): <br />16 1/2 <br />Final Reading (RF). <br />Test Duration (TF — Ti): <br />HR <br />HR <br />0 <br />0 <br />Change in Reading (RF - Rj): <br />Pass/Fail Threshold or <br />Criteria: <br />7-7 <br />on repairs made prior to testing <br />Test Result. <br />Comments — (include information <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR <br />I hereby certify that all the information contained in this report is tr <br />Technician's Signature: <br />State laws and regulations do not currently require testing to be <br />may be more stringent. <br />)R INFORMATION <br />95632 (209) 744-0112 Fax: (209) 744-0116 <br />mmo ❑ David A. Winkler ❑ Felix G. Ramirez <br />UT 5263373 -UT 5273934 -UT <br />yG INFORMATION <br />❑ Other <br />Equipment Resolution: 1/16" <br />MMMEE0=03 <br />DIESEL y 3 4 <br />U Direct Bury L <br />❑ Contained in <br />in Sump Sump S1 <br />HR <br />Direct Bury <br />Contained in <br />HR <br />and recommended <br />NDUCTING THIS TESTING <br />accurate, and in full compliance with legal requirements. <br />Date: 11/10/10 <br />by a qualified contractor. However, local requirements <br />