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RN, A§y 2006 <br />Spill Bucket Testing Report Form ENVIRONMENTAI <br />This form is intended for use by contractors performing annual testing of UST spill containment structu e rbnd <br />printouts from tests (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: LODI PAC PRIDE Date of Testing: 6-24-16 <br />Facility Address: 351 N BECKMAN LODI CA <br />Facility Contact: TED Phone: <br />Date Local Agency Was Notified of Testing: 6-2-16 <br />Name of Local Agency Inspector (if present during testing): ARIS <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: ❑ 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: ® Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: H2O & TAPE MEASURE <br />Equipment Resolution: 1/16 <br />.. m .. <br />Identify Spill Bucket (By Tank 1 DSL AB <br />Number, Stored Product, etc. <br />.. ... <br />2 91 <br />.:.... <br />3 87 <br />,...:,6 .... .. .. <br />4 <br />® Direct Bury <br />Bucket Installation Type: <br />❑Contained in Sump <br />® Direct Bury <br />❑Contained in Sump <br />® Direct Bury <br />El Contained in <br />Sump <br />❑ Direct Bury <br />E] Contained in <br />Sum <br />Bucket Diameter: 11 <br />11 <br />11 <br />Bucket Depth: 13 <br />13 <br />13 <br />Wait time between applying NA <br />vacuum/water and start of test: <br />NA <br />NA <br />NA <br />Test Start Time (Ti): 9 <br />9 <br />9 <br />Initial Reading (Ri): 12 <br />12 <br />12.75 <br />Test End Time (TF): 10 <br />10 <br />10 <br />Final Reading (RF): 12 <br />12 <br />12.75 <br />Test Duration (TF — TI): 1 HR <br />1 HR <br />1 HR <br />Change in Reading (RF - Rj): 0 <br />0 <br />O <br />Pass/Fail Threshold or 1/16 <br />Criteria: <br />1/16 <br />1/16 <br />Test Result: ; ® Pass ❑ Fail <br />®'Pass ❑ Fail <br />M Pass ❑ Fail <br />❑ Pass ❑ 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: T6—j <br />Date: 6-24-16 <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 />