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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 thefacility owner/operator for submittal to the local regulatory agency. <br /> 1.FACILITY INFORMATION <br /> Facility Name: VDP-RIPON CFNDate of Testing: 01-19-18 <br /> Facility Address: 816 FRONTAGE RD RIPON CA 95336 <br /> Facility Contact: TED I Phone: 209-649-8308 <br /> Date Local Agency Was Notified of Testing:12-19-17 <br /> Name of Local Agency Inspector(ifpresent during testing): SAN JOAQUIN CO ELIANNA FLORIDO <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 Sterns ❑ Zane A.Nimmo ❑ David A.Winkler ® Felix G.Ramirez <br /> 814188-UT 8211269-UT 5263373-UT 5273934-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/H2O Equipment Resolution: <br /> Identify Spill Bucket (By Tank 1 87 2 91 3 DIESEL 4 <br /> Number, Stored Product, etc. <br /> ❑ Direct Bury El Direct Bury E]Direct Bury ❑ Direct Bury <br /> Bucket Installation Type: ® Contained in ❑ Contained in <br /> ® Contained in Sump ®Contained in Sump <br /> Sump Sum <br /> Bucket Diameter: 11 11 11 <br /> Bucket Depth: 15 15 15 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Tj): 945 945 945 <br /> Initial Reading(Ri): 14 14 14 <br /> Test End Time(TF): 1045 1045 1045 <br /> Final Reading(RF): 14 14 11 <br /> Test Duration(TF—Tj): 1 HOUR 1 HOUR 1 HOUR <br /> Change in Reading(RF-Ri): 1 0 0 3 <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 recommendedfollow-up forfailed tests) <br /> PHIL TITE BUCKET <br /> DIESEL BUCKET LEAKS FROM LID WATER IS GOING INTO <br /> FILL SI_IMP Elite IV to repair&retest. <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 /> / <br /> Technician's Signature: U Date:01-19-18 <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 />