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NOV 2 3 2015 <br /> Spill Bucket Testing Report Form ENVIROMPkt-ary 2006wralTl,nCuao'raaCAlT <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 /> 1. FACILITY INFORMATION <br /> Facility Name: CHARTER WAY CHEVRON Date of Testing: 10-23-15 <br /> Facility Address: 508 W CHARTER WAY STOCKTON CA <br /> Facility Contact: RINKU Phone: 209-465-3440 <br /> Date Local Agency Was Notified of Testing:9-22-15 <br /> Name of Local Agency Inspector(ifpresent during testing): SAN JOQUIN CO <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2na 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: TAPE/H20 Equipment Resolution: 1/16 <br /> Identify Spill Bucket(By Tank 1 87 2 87 3 91 4 <br /> Number, Stored Product, etc. <br /> ®Direct Bury El Direct Bury <br /> Bucket Installation Type: ®Direct Bury ®Direct Bury ❑Contained in ❑Contained in <br /> ❑Contained in Sump ❑Contained in Sump Sum Sum <br /> Bucket Diameter: I 1 11 11 <br /> Bucket Depth: 13 13 13 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 935 935 935 <br /> Initial Reading(Rj): 12 12 12 <br /> Test End Time(TF): 1035 1035 1035 <br /> Final Reading(RF): 12 12 12 <br /> Test Duration IT,—Tj): 1 HOUR l HOUR 1 HOUR <br /> Change in Reading(RF-Ri): 0 0 0 <br /> Pass/Fail Threshold or _ <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 /> OPBUCKETS <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: fr—� Date:10-23-15 <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 />