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SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intendedfor 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: SHELL OIL DISTRIBUTION CENTER Date of Testing: 10/4/11 <br /> Facility Address: 3515 NAVY DR. STOCKTON, CA 95203 <br /> Facility Contact: MIKE TORRES Phone: <br /> Date Local Agency Was Notified of Testing :9/19/11 <br /> Name of Local Agency Inspector ftfpresent during testing): STACY <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 ® 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 /> IONIC <br /> Identify Spill Bucket(By Tank I WASTEWATER 2 3 4 <br /> Number, Stored Product, etc) <br /> ❑Direct Bury ❑Direct Bury ❑Direct Bury Ll Direct Bury <br /> Bucket Installation Type: ❑ Contained in ❑Contained in <br /> ® Contained in Sump ElContained in Sump SumpSum <br /> Bucket Diameter: 11 <br /> Bucket Depth: 11 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Tj): 0920 <br /> Initial Reading(RO: 10 7/8 <br /> Test End Time(TF): 1020 <br /> Final Reading(RF): 10 7/8 <br /> Test Duration(TF—Ti): HR HR HR HR <br /> Change in Reading(RF-R,): 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: 2..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 /> 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 /> ti <br /> Technician's Signature: � Date:-10-4-11 <br />