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4pRECEIED W 4S ��, January 2006 ' Spill Bucket Testing Report Form AUG 2 This form is intended for use by contractors performing annual testing of UST spill containme t,��il q�s��Ajn#E to and printouts from tests (f applicable), should be provided to the facility owner/operator for s j�� }�i�`�jo'— ry agency- DOOM gency. 7FPA Of 1 _ FACii.ITV INFORMATION Facility Name: LODI PAC PRIDE Date of Testing: 06-27-17 Facility Address: 351 N BECKMEN RD LODI CA Facility Contact: TED Phone: Date Local Agency Was Notified of Testing :5-17-17 Name of Local Agency Inspector (ifpresent during testing): SAN JOAQUIN CO GARETT 2. TESTING CONTRACTOR INFORMATION CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING I hereby certify that all the information contained in this report is true, accurate, and in full compliance with legal requirements. Technician's Signature: Date:06-27-17 ' State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more stringent. Company Name: AFFORDA TEST 4162 n1 Street Galt, CA 95632 (209) 744-0112 Fax: (209) 744-0116 Technician Conducting Test: ❑ Ed Stearns ❑ Zane A. Nimmo ❑ David A. Winkler ® Felix G. Ramirez 8184188 5263322 -UT 5263373 -UT 5273934 -UT Credentials': ® ICC Service Tech. ® SWRCB Tank Tester 3. SPILL BUCKET TESTING INFORMATION Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other Test Equipment Used: TAPE / H2O Equipment Resolution: 1/16 Identify Spill Bucket (By Tank Number, Stored Product, etc. 1 DIE 2 87 3 91 4 RED DIE 5 DIE 2 ` Bucket Installation Type: ❑ Direct Bury ® Contained in Sump ❑ Direct Bury ® Contained in Sump ❑ Direct Bury ® Contained in Sump ❑ Direct Bury ® Contained in Sump ❑ Direct Bury ® Contained in Sum Bucket Diameter: 11 11 11 11 11 Bucket Depth: 13 13 13 13 13 Wait time between applying vacuum/water and start of test: - - - - - Test Start Time (Ti): 1300 1300 1300 1300 1300 Initial Reading (Rj): 12 12 12 12 12 Test End Time (TF): 1400 1400 1400 1400 1400 Final Reading (RF): 12 12 12 12 12 Test Duration (TF — Tj): 1 HOUR 1 HOUR 1 HOUR 1 HOUR 1 HOUR Change in Reading (RF - Rj): 0 0 0 0 0 Pass at Threshold or Criteria: Test IRult; ®Pass ❑ Fad 0 Pass ❑® Pass ❑ Fail j® Pass ❑ Fad' Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING I hereby certify that all the information contained in this report is true, accurate, and in full compliance with legal requirements. Technician's Signature: Date:06-27-17 ' State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more stringent.