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.cel. SWRCB, January 2006 Spill Bucket Testing Report Form AUG Mr>>2 Z01 This form is intended for use by contractors performing annual testing of UST spill containment structures. The completed form and printouts from tests (f applicable), should be provided to the facility owner/operator for submi 9 ; . agY:-T 1_ FACTI.TTV INFORMATION Facility Name: Name: LODI PAC PRIDE I 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 (if present during testing): SAN JOAQUIN CO GARETT 2. TESTING CONTRACTOR INFORMATION Company Name: AFFORDA TEST 416 2nd 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 c.PTT.I. RTICKF.T TF,CTINC INFnRMATION 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 (Ri): 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 — TI): 1 HOUR 1 HOUR 1 HOUR 1 HOUR 1 HOUR Change in Reading (RF - Ri: 0 0 0 0 0 Pass/Fail Threshold or Criteria: _ Test Result: ® Pass ❑ Fail FS Pass ❑ Fail ® Pass ❑ Fail ® Pass ❑ Fail ® Pass ❑ Fail 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.