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r <br />SWRCB, January 2006 <br />Spill Bucket Testing Report Form <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 />Facility Name: VAN De POL -^LODI PAC PRIDE Date of Testing: 6/25/2015 <br />Facility Address: 351 N. BECKMAN RD. LODI , CA 95240 <br />Facility Contact: Phone: <br />Date Local Agency Was Notified of Testing :5/26/2015 <br />Name of Local Agency Inspector (ifpresent during testing): ARIS JUL <br />Company Name: AFFORDA TEST 416 2nd Street Galt, CA 95632 (209) 7441dP 16 <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: TAPE MEASURE, <br />H2O <br />2 87 OCTANE <br />El Direct Bury <br />® Contained in Sump <br />Equipment Resolution: <br />3 91 OCTANE <br />❑ Direct Bury <br />Contained in <br />Sump <br />1/16" <br />4 DIESEL / <br />DIESEL <br />Direct Bury <br />Contained in <br />Sum <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc. <br />Bucket Installation Type: <br />1 RED DIESEL <br />F-1Direct Bury <br />® Contained in Sump <br />Bucket Diameter: <br />11 <br />11 <br />11 <br />11 -- 11 <br />Bucket Depth: <br />13 <br />13 <br />13 <br />13 -- 13 <br />Wait time between applying <br />vacuum/water and start of test: <br />_ <br />__ <br />__ <br />__ <br />Test Start Time (TI): <br />0856 <br />0856 <br />0856 <br />0856 -- 0856 <br />Initial Reading (RI): <br />9 1/2 <br />10 1/4 <br />10 1/2 <br />12 -- 12 <br />Test End Time (TF): <br />0956 <br />0956 <br />0956 <br />0956 -- 0956 <br />Final Reading (RF): <br />9 1/2 <br />10 1/4 <br />10 1/2 <br />12 -- 0956 <br />Test Duration (TF — TI): <br />HR <br />HR <br />HR <br />H R <br />Change in Reading (RF - RI): <br />0 <br />0 <br />0 <br />0 -- 0 <br />Pass/Fail Threshold or <br />Criteria: <br />_ <br />-- <br />CommelttS — (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: 6-25-15 <br />' State laws and regulations do not currently require testing to be performed by a qualified contractor. However, locA requirements <br />may be more stringent. <br />