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r y <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,fornr 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 I Date of Testing: 7/28/10 <br /> Facility Address: 6421 CAPITOL AVE. LODI,CA 95242 <br /> Facility Contact: KIU Phone: 209-334-1873 <br /> Date Local Agency Was Notified of Testing :7/26/10 <br /> Name of Local Agency Inspector(ifpresent during testing): ARTS CACAPIT <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2`1 Street Galt,CA 95632 (209)744-0112 Fax: (209) 744-01 16 <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 /> �Identifyill Bucket(By Tank 1 87 2 87 SLAVE 3 91 4 DIESEL <br /> ored Product, etc.) <br /> ❑ Direct Bury Direct Bury <br /> ❑ Direct Bury ❑ Direct Bury <br /> Bucket Installation Type: ® Contained in Sump ®Contained in Sump ® Contained in ® Contained in <br /> Sum Sum <br /> Bucket Diameter: 1 I I I 11 11 <br /> Bucket Depth: 15 15 14 1/2 15 <br /> Wait time between applying _- <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 1220 1340 1220 1340 <br /> Initial Reading(Rj): 14 14 13 14 <br /> Test End Time(TF): 1320 1440 1320 1440 <br /> Final Reading(RF): 14 14 13 14 <br /> Test Duration(TF—Tj): HR HR HR HR <br /> Change in Reading(RF-Rj): 0 0 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: ® Pass ❑ Fail ® Pass ❑ Fail ® Pass ❑ Fail ® Pass ❑ Fail <br /> Comments— (include information on repairs made prior to testing, and)•ecommended 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:7/26/10 <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 />