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SWRCB,January 2006 <br /> Spill Bucket Testing Report 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: VDP-LODI PACIFIC PRIDE I Date of Testing: 6/22/2018 <br /> Facility Address: 351 N.BECKHAM ROAD LODI,CA 95240 <br /> Facility Contact: I Phone: <br /> Date Local Agency Was Notified of Testing:5/3 0/2018 <br /> Name of Local Agency Inspector(if present during testing): NONE PRESENT <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 /> 8883080-UT 8883064-UT 8883059-UT 8883072-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, H2O Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By Tank 1 RED DIESEL 2 87 3 91 4 DSL T-4- <br /> Number, Stored Product, etc.) DSL T-5 <br /> E]Direct Bury El Direct Bury <br /> Bucket Installation Type: El Direct Bury El Direct Bury ® Contained in <br /> ®Contained in Sump ®Contained in Sump ® Contained in <br /> Sump Sum <br /> Bucket Diameter: 11 11 11 11 - 11 <br /> Bucket Depth: 13 13 13 13 - 13 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 1030 1030 1030 1145 - 1145 <br /> Initial Reading(Rj): 12 1/4 12 1/2 12 1/4 12 1/2- 12 1/4 <br /> Test End Time(TF): 1130 1130 1130 1245 - 1245 <br /> Final Reading(RF): 12 1/4 12 1/2 12 1/4 12 1/2 - 12 1/4 <br /> Test Duration(TF—TI): H O U R <br /> Change in Reading(RF-RI): 0 0 0 0 - 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: ® Pass ❑Fail ® Pass ❑Fail ® Pass ❑Fail ® Pass ❑Fail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> FIVE SPILL BUCKETS TESTED 3 FIRST, THEN 2 AFTER NOT ALL AT THE SAME TIME <br /> ALL MEASURED 5 GALLONS <br /> E• sa e� <br /> 71,c, <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING ai'�VIROl'��l ENTAL <br /> I hereby certify that all the information contained in this report is true,accurate,and in full compliance withgalrlgi� tpf��E�.�T <br /> 7k <br /> Technician's Signature: Date: 6/22/2018 <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 />