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Pi <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 _ FAC'IT.TTV INFORMATION <br />Facility Name: KETTLEMEN CHEVRON Date of Testing: 07-26-10 <br />Facility Address: 601 KETTLEMEN LN LODI CA _ <br />Facility Contact: TONY <br />Phone: 209-333-0305 <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (if present during testing): SAN JOAQUIN CO <br />2. TF,STING CONTRACTOR INFORMATION <br />Company Name: AFFORDA TEST 4162 d 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 />II Credentials': ® ICC Service Tech. ® SWRCB Tank Tester 11 <br />I_ gPTT.T. RIiC..KF.T TESTING INFORMATION <br />Test Method Used: ® Hydrostatic _ ❑ Vacuum ❑ Other <br />Test Equipment Used: TAPE / H2O <br />Equipment Resolution: 1/16 J <br />2 87 <br />3 91 <br />4 DIE <br />l <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />1 87 <br />Bucket Installation Type: <br />❑ Direct Bury <br />®Contained in Sump <br />❑ Direct Bury <br />®Contained in Sump <br />® Direct Bury <br />❑ Contained in <br />Sum <br />❑ Direct Bury <br />® Contained in <br />Sum _ <br />Bucket Diameter: <br />11 <br />11 <br />11 <br />11 _ <br />Bucket Depth: <br />13 <br />13 <br />13 <br />13 <br />Wait time between applying <br />vacuum/water and start of test: <br />_ <br />_ <br />- <br />- <br />Test Start Time (Ti): <br />1030 <br />1130 <br />Initial Reading (Rj): <br />13 <br />13 <br />Test End Time (TF): <br />1130 <br />1230 <br />Final Reading (RF): <br />13 <br />13 <br />Test Duration (TF — Tj): <br />1 HOUR <br />1 HOUR <br />Change in Reading (RF - RI): <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />_ <br />- <br />Test Result: <br />❑ <br />Pass < ❑ Fail <br />1, <br />[ ]Pass ❑ <br />Iail <br />2 Pass ❑ Fail <br />® Pass ❑ Fail <br />Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />DID NOT TEST 87 BUCKETS. THEY WERE NOT PUT TOGETHER _.___ <br />PROPERLY TO TEST. <br />**TO BE REPAIRED & RETESTED BY ELITE IV <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: <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 />