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SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intended for use by contractors pet forming annual testing of UST spill containment structures. The completed form ata <br /> printouts from tests (f 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: 7-28-2011 — <br /> Facility Address: 6421 CAPITAL LODI CA <br /> Facility Contact: Phone: _ <br /> [�D� <br /> ate Local Agency Was Notified of Testing <br /> Name of Local Agency Inspector(if present during testing): MICHELLE <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 ther <br /> Test Equipment Used: h20 and tape measure Equipment Resolution: 1/16 <br /> identify Spill Bucket ([3v Tank 1 87M 2 87S 3 91 4 DSL <br /> Number, Stored Product, etc.) <br /> ❑ Direct Bury ❑ Direct Bury <br /> Bucket Installation Type: ❑ Direct Bury ❑ Direct Bury ® Contained in ® Contained in <br /> ® Contained in Sump ® Contained in Sump Sum Sum <br /> Bucket Diameter: I l 1 1 I l 11 <br /> Bucket Depth: 15 15 14 15.50 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 920 920 920 920 <br /> Initial Reading(Rt): 13 14 13 14 <br /> Test End Time(TF): 1020 1020 1020 1020 <br /> Final Reading(RF): 13 14 13 14 <br /> Test Duration(TF—Ti): IHR IHR IHR IHR <br /> Change in Reading(RF-Ri): 0 0 0 O <br /> Pass/Fail Threshold or 1/16 1/16 1/16 1/16 <br /> Criteria: - <br /> Test Result: ® 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 /> 1 hereby certify that all the information contained in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: V —i Date 7-28-2011 <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 />