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0 • 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 /> 1. FACILITY INFORMATION <br /> Facility Name: MORADA CHEVRON Date of Testing: 1/21/10 <br /> Facility Address: 10878 N. HWY 99 STOCKTON, CA 95212 <br /> Facility Contact: Bill Phone: <br /> Date Local Agency Was Notified of Testing:1/12/10 <br /> Name of Local Agency Inspector(fpresent during testing): TWI <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 4162 nd 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 MEASURE, H2O Equipment Resolution: 1/16" <br /> Identify Spill Bucket (By Tank 1 87 2 89 3 91 4 DIESEL <br /> Number, Stored Product, etc.) <br /> Direct Bury Direct Bury <br /> Bucket Installation Type: ® Direct Bury ® Direct Bury ❑ Contained in El Contained in <br /> ❑ Contained in Sump ❑ Contained in Sump Sum Sum <br /> Bucket Diameter: 11 11 11 11 <br /> Bucket Depth: 13 12 12 l6 <br /> Wait time between applying - -- <br /> vacuum/water and start of test: <br /> Test Start Time(T,): 1330 <br /> 1330 1330 1330 <br /> Initial Reading(Ri): 12- 11- 11- 15 1/2 <br /> Test End Time(TF): 1430 1430 1430 1430 <br /> Final Reading(RF): 12- <br /> 11- 11- 15 1/2 <br /> HR <br /> Test Duration(TF—Tj): HR HR HR 0 <br /> Change in Reading(RF-Rj): 0 0 0 0 <br /> Pass/Fail Threshold or - -- <br /> Criteria: <br /> Test Result: Z Pass ❑ Fail Z Pass ❑ Fail ® Pass ❑ Fail Pass ❑ Fail <br /> Comments (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: 1-21-10 <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 />