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08/22/2012 11:44AN FAX 2093330318 KSN CORP 0008/0008 <br /> SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intended for use by contractors performing annual testing of U,571'spill containment structures. The completed form crud <br /> printouts from tests(if applicahle), should be provided to the futility ownerloperatorfor submittal to the local regulatory agency. <br /> 1. FACILITY TNFORMATION <br /> Facility Name: KEWLEMEN CHEVRON Date offcsting- 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 /> LocalName of Agency inspector(if present during tesfing): SAN JOAQUIN CO MUNI <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416'2"Street Galt,CA 95632 (209)744-0112 Fax:(209)744-0116 <br /> Technician Conducting Test: Lyle D.Nimmo C] Zane A.Nimmo [] David A. Winkler 0 Felix G.Ramirez <br /> 5249115-UT 5263322-UT 5263373-UT 5273934-UT <br /> Credentials': Z ICC Service Tech. SWPCB Tank Tester <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: Hydrostatic El Vacuum 0-6ih—or <br /> Test Equipment Used: TAPE/H2O Equipment Resolution: 1/16 <br /> Identify Spill Bucket(By Tank 1 87 2 87 3 91 4 DTE <br /> Number, Stored Product,etc) El Dinxi Bu Direct N Direct Bury Direct Bury <br /> Bucket Installation Type: Bury Bury 0 Contained in Contained in <br /> 0 Contained in Sump Contained in Sump Sum Sump <br /> Bucket Diameter: I I I 1 11 <br /> Bucket Depth: 13 13 13 13 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> 'rest Start Time(Ti)-* 1030 1036 1030 1130 <br /> Initial Reading(1Q. 12 12 12 12 <br /> Test End Time(TF): 1130 1130 1130 1130 <br /> Final Reading(F*): 12 111/2 12 12 <br /> Test Duration(TF—Tr): I HOUR 1 HOUR I HOUR I HOUR <br /> Change in Reading(R+--Ra): 0 1/2 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> 1191" 1"'l-, MINIM- <br /> IMF; �70 <br /> Cow m ents—(include information on repairs made prior to testing, and rvcoM2!�ed{allow-rip&falled lavuy <br /> RING IN CNI BIJCKET IS BROKE. ELITE 4 WILL FIX <br /> CERTIFICATION OF TEC14NICIAN RESPONSIBLE FOR CONT)tJ(.TING THIS 1"ESTING <br /> I hereby certify that all the information contained in this report is true,accurate,and in full complimnec,with legal requirements. <br /> Technician's Signature: Date:07-2412 <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 />