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• • SWRCB, January 2006 <br />Spill Bucket Testing Report Form <br />This form i intended for use by contractors performing annual testing of UST spill containment structures. The completed form and <br />printouts f om tests (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility N e: TOKAY SHELL Date of Testing: 1/5/10 <br />Facility Adc ress: 420 W. KETTLEMAN LN. LODI, CA 95240 <br />Facility Cor tact: JAS Phone: 209-369-2790 <br />Date LocalAgency Was Notified of Testing :12/29/09 <br />Name of Lo al Agency Inspector (ifpresent during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />Company IN ame: AFFORDA TEST 4162 "d Street Galt, CA 95632 (209) 744-0112 Fax: (209) 744-0116 <br />Technician onducting 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 Equipe tent Used: TAPE MEASURE, H2O <br />Equipment Resolution: 1/16" <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />1 87 <br />2 91 <br />3 100 OCT <br />4 DIESEL / <br />WASTE OIL <br />Bucket Inst Ilation Type: <br />® Direct Bury <br />❑ Contained in Sump <br />® Direct Bury <br />❑ Contained in Sump <br />® Direct Bury <br />❑ Contained in <br />SumpSum <br />® Direct Bury <br />❑ Contained in <br />Bucket Diameter: <br />1 I <br />11 <br />I I <br />1 I 1 1 <br />Bucket Depth: <br />12 <br />14 <br />13 <br />13 --- I I <br />Wait time between applying <br />vacuum/wa er and start of test: <br />__ <br />Test Start Time (T[): <br />930 <br />930 <br />930 <br />930 --- 1200 <br />Initial Reading (Ri): <br />11 1/8 <br />125/8 <br />12 1/2 <br />12 1/4 --- 105/8 <br />Test End Time (TF): <br />1030 <br />1030 <br />1030 <br />1030 --- 1300 <br />Final Reading (RF): <br />11 1/8 <br />125/8 <br />12 1/2 <br />12 1/4 --- 10 5/8 <br />Test Durati n(TF —Ti): <br />HR <br />HR <br />HR <br />HR --- HR <br />Change in eading(RF -Ri): <br />0 <br />0 <br />1 0 <br />0 0 <br />Pass/Fail T reshold or <br />Criteria: <br />PASS <br />Test Resu t <br />Z Pass ❑ Fail <br />® Pass ❑ Fail <br />I Z Pass ❑ Fail <br />1 ® Pass ❑ Fail <br />Commenks — (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 />1 hereby ce tify that all the information contained in this report is true, accurate, and in full compliance with legal requirements. <br />Signature: e Date: 1-5-10 <br />State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements <br />may be njore stringent. <br />