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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: KETTLEMEN CHEVRON Date of Testing: 07-24-12 <br /> Facility Address: 601 KETTLEMEN LN LODI CA <br /> Facility Contact: TONY Phone: 209-333-0305 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(fpresent during testing): SAN JOAQUIN CO MUNI <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 /> ®Direct Bury F-1DirectBury <br /> Bucket Installation Type: F1 Direct Bury F1 Direct Bury F1 Contained in ® Contained in <br /> ®Contained in Sump ®Contained in Sump Sump Sum <br /> Bucket Diameter: 11 I 1 11 11 <br /> Bucket Depth: 13 13 13 13 <br /> Wait time between applying <br /> vacuum/water and start of test: - <br /> Test Start Time(TI): 1030 1030 1030 1130 <br /> Initial Reading(RI): 12 12 12 12 <br /> Test End Time(TF): 1130 1130 1130 1130 <br /> Final Reading(RF): 12 11 1/2 12 12 <br /> Test Duration(TF—TI): 1 HOUR 1 HOUR 1 HOUR 1 HOUR <br /> Change in Reading(RF-RI): 0 1/2 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> et h ❑ ® . <br /> Comments— (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> RING IN CNI BUCKET IS BROKE. ELITE 4 WILL FIX <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:07-24-12 <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 />