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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(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: JULY 30,2009 <br /> Facility Address: 6421 CAPITAL LODI CALIFORNIA <br /> Facility Contact: KIU Phone: 209-334-0975 <br /> Date Local Agency Was Notified of Testing:7/28 <br /> Name of Local Agency Inspector(rf present during testing: SAN JOAQUIN CO <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 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: <br /> El Direct Bury El Direct Bury ® Contained in ®Contained in <br /> ® Contained in Sump ® Contained in Sump SumpSum <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): 1 830 830 830 830 <br /> Initial Reading(R,): <br /> 14 13 13 14 <br /> Test End Time(TF): 930 930 930 930 <br /> Final Reading(RF): 14 13 13 14 <br /> Test Duration(TF—Tj): 1 HOUR 1 HOUR 1 HOUR 1 HOUR <br /> Change in Reading(RF-Ri): 0 0 0 0 <br /> Pass/Fail Threshold or 0 0 0 0 <br /> Criteria: <br /> Test Result: ® Pass ❑ Fail ® Pass ❑ Fail ® Pass El Fail ® Pass ❑ FailJI <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: <br /> Date: 7-30-09 <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 />