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SWRCB, January 2006 This form is intended for use by contractors performing annual testing of UST spill containment structures. The completed form and printouts from tests (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: VAN De POL - LODI PAC PRIDE I Date of Testing: 6/25/2015 Facility Address: 351 N. BECKMAN RD. LODI , CA 95240 Facility Contact: Phone: Date Local Agency Was Notified of Testing :5/26/2015 Name of Local Agency Inspector (if present during testing): ARIS 2. TESTING CONTRACTOR INFORMATION Company Name: AFFORDA TEST 4162 d Street Galt, CA 95632 (209) 744-0112 Fax: (209) 744-0116 Technician Conducting Test: ❑ Lyle D. Nimmo ® Zane A. Nimmo ❑ David A. Winkler ❑ Felix G. Ramirez 5249115 -UT 5263322 -UT 5263373 -UT 5273934 -UT Credentials': ® ICC Service Tech. ® SWRCB Tank Tester 3. SPILL BUCKET TESTING INFORMATION Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other Test Equipment Used: TAPE MEASURE, H2O Equipment Resolution: 1/16" Identify Spill Bucket (By Tank Number, Stored Product, etc.) 1 RED DIESEL 2 87 OCTANE 3 91 OCTANE 4 DIESEL / DIESEL Bucket Installation Type: ❑ Direct Bury ®Contained in Sump El Direct Bury ®Contained in Sump ❑ Direct Bury ® Contained in Sum ❑ Direct Bury ® Contained in Sum Bucket Diameter: i l 11 11 11 -- I 1 Bucket Depth: 13 13 13 13 -- 13 Wait time between applying vacuum/water and start of test: Test Start Time (Ti): 0856 0856 0856 0856 -- 0856 Initial Reading (Rj): 9 1/2 10 1/4 10 1/2 12 -- 12 Test End Time (TF): 0956 0956 0956 0956 -- 0956 Final Reading (RF): 9 1/2 10 1/4 10 1/2 12 -- 12 Test Duration (TF — Tj): HR HR HR H R Change in Reading (RF - Rj): 0 0 0 0 -- 0 Pass/Fail Threshold or Criteria: _ - Test Result: Z Pass El Fail ® Pass ❑ Fail ® Pass ❑ Fail Z Pass ❑ Fail Ik li 10 70ts CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING .--E 1-- ,9 P_" I hereby certify that all the information contained in this report is true, accurate, and in full compliance with legal requirements. Technician's Signature - ® -" Date: 6-25-15 ' State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more stringent.