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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(if applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1.FACILITY INFORMATION <br /> Facility Name: WEST LANE CHEVRON I Date of Te <br /> Facility Address: 4747 WEST LANE STOCKTON, CA 1AL. <br /> Facility Contact: Rinku Phone: 472-1639 <br /> Date Local Agency Was Notified of Testing:8/25/2016 2 7 2016 <br /> Name of Local Agency Inspector(f present during testing): VICKI <br /> 2. TESTING CONTRACTOR INFORMATION C:MA AL HEALTH <br /> Company Name: AFFORDA TEST 416 2nd Street Galt,CA 95632 (209)744-0112 Fax: (20'vi 4-0116 <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 MEASURE, H2O Equipment Resolution: 1/16" <br /> Identify Spill Bucket (B'v Tank 1 91 2 87 MIDDLE 3 87 EAST 4 <br /> Vumber, Stored Product, etc.) <br /> ❑Direct Bury ❑Direct Bury ❑ Direct Bury ❑ Direct Bury <br /> Bucket Installation Type: ® Contained in ❑ Contained in <br /> ®Contained in Sump ®Contained in Sump Sump Sum <br /> Bucket Diameter: I I 1 1 11 <br /> Bucket Depth: 13 14 13 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Tj): 0950 0950 0950 <br /> Initial Reading(RI): 12 1/2 13 1/2 13 <br /> Test End Time(TF): 1050 1050 1050 <br /> Final Reading(RF): 10 1/2 11 3/4 13 <br /> Test Duration(TF–T,): HR HR HR HR <br /> Change in Reading(RF-R,): -2.00 -13/4 13 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: L ❑ 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 /> 87 MIDDLE AND 91 BOTH HAD BAD DRAIN VALVES <br /> NO PARTS AVAILABLE FOR REPAIR TODAY WILL SCHEDULE <br /> ELITE IV FOR INSTALLATION–Repair and retest by others. <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 e 0<t Z Date:-9-29-16 <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 />