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• <br />Ll <br />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 Ti ArI1111TV INF(IRMATION <br />Facility Name: KETTLEMAN CHEVRON Date of Testing: 7-20-2011 <br />Facility Address: 601 E KETTLEMAN LN LODI C A <br />Facility Contact: TONY Phone: <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (f present during testing): ARIS <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 />I Credentials': ® ICC Service Tech. ® SWRCB Tank Tester <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used h20 and tape measure <br />Equipment Resolution. 1/16 <br />:.Sfn'ih: £Rk. .: ih x.vr.X ..✓.. :tet" lt+xm: .,:,OM1 xya 1, Nx?5. . ,. .,n:.. .,.._ o ,mz .i ..'+..9�. <br />t?.+fi'.M1Lv.t,.4: ..,a a ..f r.,»., <br />,r', ,... <br />XYH. <br />4 DSL <br />Identify Spill Bucket (By Tank 1 87W <br />Number, Stored Product, etc. <br />2 87E <br />3 91 <br />Bucket Installation Type: ❑ Direct Bury <br />®Contained in Sump <br />E] Direct Bury <br />®Contained in Sump <br />® Direct Bury <br />El Contained in <br />Sump <br />F] Direct Bury <br />® Contained in <br />Sump <br />Bucket Diameter: 11 <br />11 <br />11 <br />11 <br />Bucket Depth: 15 <br />15 <br />14 <br />13 <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (Ti): 830 <br />830 <br />830 <br />830 <br />Initial Reading (Rj): 13.75 <br />14 <br />13 <br />12.50 <br />Test End Time (TF): 930 <br />930 <br />930 <br />930 <br />Final Reading (RF): <br />13.75 <br />14 <br />13 <br />12.50 <br />Test Duration (TF — TI): <br />IHR <br />IHR <br />IHR <br />IHR <br />Change in Reading (RF - RI): <br />0 <br />0 <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />1/16 <br />1/16 <br />1/16 <br />1/16 <br />Test Result: <br />® Pass ❑ Fail <br />I ® Pass ❑ Fail <br />® Pass ❑ Fail <br />® Pass ❑Fail <br />Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) <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: <br />Date 7-19-2011 <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 />