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! 0 <br /> Spill Bucket Testing Report Form S WRCB,January 2006 <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: E.F.KLUDT&SONS Cardlock I Date of Testing: 4/4/13 <br /> Facility Address: 1126 E.PINE ST. LODI,CA 95240 <br /> Facility Contact: STEVE Phone: 209-368-0634 <br /> Date Local Agency Was Notified of Testing:3/29/13 <br /> Name of Local Agency Inspector(rfpres--during testing): ARIS <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 4162 nd Street Galt,CA 95632 (209)744-0112 Fax:(209)744-0116 <br /> Technician Conducting Test: ❑Lyle D.Nimmo ® Zane A.Nimmo ❑ David A. Winkler ❑ Felix G.Ramirez <br /> 5249115-UT 5263322-UT 5263373-UT 5273934-UT <br /> Credentials': ® ICC Service Tech. ® SWRCB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: 1771 ,- , static ❑Vacuum ❑Other <br /> Test Equipment Used: TAPE MEASURE, H2O Equipment Resolution: 1/16" <br /> Identify Spill Bucket (By Tank 1 20K DIESEL 2 2 RED DYED DIE 3 RED DIESEL 4 <br /> Number, Stored Product, etc.) MAIN SYPHON <br /> Bucket Installation Type: ® Direct Bury ® Direct Bury ® Direct Bury ❑Direct Bury <br /> ❑ Contained in Sump ❑ Contained in Sump ❑Contained in ❑Contained in <br /> Sum Sum <br /> Bucket Diameter: 11 I I 1 I <br /> Bucket Depth: 11 14 11 <br /> Wait time between applying <br /> vacuum/water and start of test: -- - <br /> Test Start Time(Tj): 1505 1045 1515 <br /> Initial Reading(Rj): 10 13 <br /> 10 <br /> Test End Time(TF): 1605 1145 1615 <br /> Final Reading(RF): 10 13 10 <br /> Test Duration(TF—Tj): HR LIR HR <br /> Change in Reading(RF-Rj): 0 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: -- - - _ <br /> Test Result: ® Pass ❑Fail ® Pass ❑ Fail M Pass F-1 El❑ Pass <br /> ❑ Fail <br /> COMMents—(include information on repairs made prior to testing, and recommended follow-up for failed tests) <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 /> Technician's Signature:_ Date: 44-13 <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 />