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Spill Bucket Testing Report Form January 2006 <br /> This form is intended for use by contractors performing annual testing of UST spill conta'EgII structures. The completed.Rk and <br /> printouts from tests(if applicable), should be provided to the facility owner/operator for C[al to the local regulatory agency. <br /> E <br /> 1. FACILITY INFORMATION <br /> Facility Name: LODI CORP YARD Date of Testing: 09-12-17 <br /> Facility Address: 1331 S HAM LANE LODI CA 95240 <br /> Facility Contact: RANDY Phone: 209-335-6830 <br /> Date Local Agency Was Notified of Testing: 08-25-17 <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2"d 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 /> 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 87S 3 DIESEL 4 <br /> Number, Stored Product, etc. <br /> ®Direct Bury ®Direct Bury ❑ Direct Bury ❑ Direct Bury <br /> Bucket Installation Type: ®Contained in E]Contained in <br /> ❑Contained in Sump E]Contained in Sump Sump Sum <br /> Bucket Diameter: 11 12 X 15 <br /> Bucket Depth: 14 24 <br /> Wait time between applying - <br /> vacuum/water and start of test: <br /> Test Start Time(TI): 1300 1300 <br /> Initial Reading(Ri): 14 23 <br /> Test End Time(TF): 1400 1400 <br /> Final Reading(RF): 14 23 <br /> Test Duration(TF—Ti): 1 HOUR 1 HOUR <br /> Change in Reading(RF-RI): 0 0 <br /> Pass/Fail Threshold or _ Closed - <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 /> 87 S Tank bucket closed—not tested, inspector Stacy W/SJC on site <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:09-12-17 <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 />