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RECEIVED <br /> OCT 2 2 2018 <br /> SWRCB,January 2006 <br /> Testing Re <br /> S ill Bucket <br /> ENVIRONMENTAL HEALTH P g ort Form P <br /> ��{�,, ded for use by contractors performing annual testing of UST spill containment structures. The completed form and <br /> pri n�touts om tests(if applicable), should be provided to the facility owner/operatorfor submittal to the local regulatory agency. <br /> 1.FACILITY INFORMATION <br /> Facility Name: FLAG CITY CHEVRON I Date of Testing: 9/26/2018 <br /> Facility Address: 6421 CAPITOL AVENUE LODI,CA 95240 <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing:8/28/2018 <br /> Name of Local Agency Inspector(ifpresent during testing): Z U N A <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2°a Street Galt,CA 95632 (209)744-0112 Fax:(209)744-0116 <br /> Technician Conducting Test: ❑ Ed Steams N Zane A.Nimmo ❑ David A.Winkler ❑ Felix G.Ramirez <br /> 8883080-UT 8883064-UT 8883059-UT 8883072-UT <br /> Credentials: N ICC Service Tech. N 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 /> Identify Spill Bucket (By Tank 1 87 SLAVE 2 91 OCTANE 3 87 MASTER 4 DIESEL <br /> Number, Stored Product, etc. <br /> F1 Direct Bury El Direct Bury El Direct Bury ❑ Direct Bury <br /> Bucket Installation Type: N Contained in N Contained in <br /> N Contained in Sump N Contained in Sump Sump Sum <br /> Bucket Diameter: 11 11 11 11 <br /> Bucket Depth: 14 1/2 12 1/4 14 1/2 14 1/2 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> 'rest Start Time(Ti): 1050 1050 1050 1050 <br /> Initial Reading(Rj): 13 1/2 10 3/4 12 3/4 13 - <br /> Test End Time(TF): 1150 1150 1150 1150 <br /> Final Reading(RF): 13 1/2 10 3/4 12 3/4 13 - <br /> Test Duration(TF—Ti): HOUR H R H R H R <br /> Change in Reading(RF-Rt): 0 0 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: N Pass ❑Fail N Pass ❑Fail N Pass ❑Fail N Pass ❑Fail <br /> Comments— (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> ALL BUCKETS MEASURED 5 GALLONS+ <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: 9/26/2018 <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 />