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SWRCB,January 2006 <br /> Spill Bucket Testing ReporMENTAL HEALTH <br /> This form is intended for use by contractors performing annual testing of UST spill contaIDERARIM.TThe 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: TOKAY SHELL Date of Testing: 1-17-2017 <br /> Facility Address: 420 W.KETTLEMAN LN. LODI,CA 95240 <br /> Facility Contact: JAS Phone: 209-369-2790 <br /> Date Local Agency Was Notified of Testing: 12-28-16 <br /> Name of Local Agency Inspector(fpresent during testing): VICKI <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2nd 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 MEASURE, H2O Equipment Resolution: 1/16" <br /> Identify Spill Bucket 1 87 2 91 3 100 OCT 3 DIE 4 <br /> (6y Tank Number,Stored WASTE OIL <br /> Product,etc.) <br /> Bucket Installation ® Direct Bury ® Direct Bury ® Direct Bury ® Direct Bury ®Direct Bury <br /> Type: ❑Contained in ❑ Contained ❑ Contained ❑ Contained in ❑Contained in <br /> Sump in Sump in Sump Sump Sump <br /> Bucket Diameter: 11 11 11 11 11 <br /> Bucket Depth: 12 14 13 13 11 <br /> Wait time between <br /> applying vacuum/water -- - - -- -- <br /> and start of test: <br /> Test Start Time(Ti): 10 10 10 10 10 <br /> Initial Reading(Ri): 11 13 12 123/4 10 1/4 <br /> Test End Time(TF): 11 11 11 11 11 <br /> Final Reading(RF): 11 13 12 123/4 10 1/4 <br /> Test Duration(TF—Tt): HR HR HR HR HR <br /> Change in Reading(RF 0 0 0 0 0 <br /> -Ri): <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: ® Pass ® Pass ® Pass ® Pass Pass <br /> Comments — (include information on repairs made prior to testing, and recommended follow-up for jailed tests) <br /> WASTE OIL BUCKET NOT 5 GAL . ABOUT 1 QT SHORT . PASSED <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: 1-17-17 <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 />