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RECEINEU <br /> 'EP $ 20I WRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intended for use by contractors performing annual testing of'UST spill(ENIVIR&NMEAe1TA TIM Nid form and <br /> printouts from tests(f applicable), should be provided to the facility owner/operator for subt6f*Aj*Airegulatory agency. <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 2nd 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 ❑Contained in <br /> ❑Contained in Sump El 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—Tj): 1 HOUR 1 HOUR <br /> Change in Reading(RF-Rj): 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 />