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, t r <br /> 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: FLAG CITY CHEVRON Date of Testing: 09-04-13 <br /> Facility Address: 6421 CAPITAL LODI CALIFORNIA <br /> Facility Contact: KIU Phone: 209-334-0975 <br /> Date Local Agency Was Notified of Testing:8-13-13 <br /> Name of Local Agency Inspector(if present during testing): SAN JOAQUIN CO <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 4162 d Street Galt,CA 95632 (209)744-0112 Fax: (209)744-0116 <br /> Technician Conducting Test: ❑Lyle D.Nimmo ❑ Zane A.Nimmo E David A. Winkler E Felix G.Ramirez <br /> 5249115-UT 5263322-UT 5263373-UT 5273934-UT <br /> Credentials': E ICC Service Tech. E SWRCB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: E Hydrostatic ❑Vacuum ❑ Other <br /> Test Equipment Used: TAPE H2O Equipment Resolution: 1/16 <br /> Identify Spill Bucket (By Tank 1 87 2 87 3 91 4 DIE <br /> Number, Stored Product, etc.) <br /> El Direct Bury ❑ Direct Bury <br /> Bucket Installation Type: El Direct Bury El Direct Bury E Contained in E Contained in <br /> E Contained in Sump E Contained in Sump Sump Sum <br /> Bucket Diameter: 11 11 11 11 <br /> Bucket Depth: 15 1/4 14 14 15 1/2 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(TI): 1100 1100 1100 1 100 <br /> Initial Reading(RI): 14 12 1/2 14 14 <br /> Test End Time(TF): 1200 1200 1200 1200 <br /> Final Reading(RF): 14 121/2 14 14 <br /> Test Duration(TF—Tj): 1 HOUR 1 HOUR 1 HOUR 1 HOUR <br /> Change in Reading(RF-Rj): 0 0 1 0 0 <br /> Pass/Fail Threshold or 0 0 0 0 <br /> Criteria: <br /> Test Result: E Pass ❑ Fail E Pass ❑ Fail E Pass ❑ Fail E Pass ❑ Fail <br /> Comments— (include information on repairs made prior to testing, and recommended follow-up for,failed tests) <br /> OPW BUCKETS <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: �Y� Date: 9-4-13_ <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 />