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Spill Bucket Testing Report Form SWRCB,January 2006 <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 thefacility owner/operatorfor submittal to the local regulatory agency. <br /> 1.FACILITY INFORMATION <br /> Facility Name: LATHROP GAS&FOOD - CHEVRON Date of Testing: 12/12/2016 <br /> Facility Address: 140 E. LATHROP RD. LATHROP, CA 95330 <br /> Facility Contact: Jesse I Phone: 209-982-5005 <br /> Date Local Agency Was Notified of Testing:l 1/21/2016 <br /> Name of Local Agency Inspector rtfpresent during testing): VICKY <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2nd Street Galt,CA 95632 (209)744-0112 Fax:(209)744-0116 <br /> Technician Conducting Test: ❑Lyle D.Nimmo N Zane A.Nimmo ❑ David A.Winkler ❑ Felix G.Ramirez <br /> 5249115-UT 5263322-UT 5263373-UT 5273934-UT <br /> Credentials': N ICC Service Tech. N SWRCB Tank Tester <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: N Hydrostatic ❑vacuum ❑Other <br /> Test Equipment Used: TAPE MEASURE, H2O Equipment Resolution: 1/16' <br /> Idecntify S;ti pill pucker(By Tank 1 87 2 3 91 4 DIESEL <br /> Number,Stored <br /> Product.etc. <br /> Bucket Installation Type: <br /> N Direct Bury ❑Direct Bury Direct Bury N Direct Bury <br /> ❑Contained is Sump El Contained in Sump ❑Contained in El Contained in <br /> Sump Sum <br /> Bucket Diameter. 11 11 11 <br /> Bucket Depth: 14 1/4 13 1/2 14 I/4 <br /> Wait time between applying <br /> vacuum/water and start of test: — — — <br /> Test Start Time(Ti): 0915 0915 0915 <br /> Initial Reading(Ri): 13 1/4 12 1/2 13 1/4 <br /> Test End Time(TF): 1015 1015 1015 <br /> Final Reading(RF): 13 1/4 12 1/2 13 1/4 <br /> Test Duration(TF—Tt): HR HR HR HR <br /> Change in Reading(RF-Ri): 0 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: -- — -- -- <br /> Test Result: N Pass ❑Fail ❑ Pass ❑Fail <br /> N Pn Fat Pass ❑Fait <br /> Comments— include information on repairs made rior to testing. and recommended fo ailed <br /> ALL BUCKETS MEASURED 5 GALLONS PLUS <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING DFPART%I r n1T <br /> I hereby certify that all the information contained in this report is true,accurate,and in fun compliance with legal requirements. <br /> Technician's Signature 6 Date: 12-12-16 <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 />