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B Januar 2006 <br />9 0 SWRC y <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: KETTLEMAN CHEVRON Date of Testing: 7-9-09 <br />Facility Address: 601 E KETTLEMAN LANE LODI CA <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 />Credentials': ® ICC Service Tech. ® SWRCB Tank Tester <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: ® Hydrostatic ❑ vacuum ❑ Other <br />Test Equipment Used: H2O & TAPE MEASURE Equipment Resolution 1/16 <br />Identify Spill Bucket (By Tank 1 87 W <br />Number, Stored Product, etc. <br />Bucket Installation Type: <br />Bucket Diameter: <br />Bucket Depth: <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (TO: <br />Initial Reading (RI): <br />Test End Time (TF): <br />Final Reading (RF): <br />Test Duration (TF — Ti): <br />Change in Reading (RF - Ri): <br />Pass/Fail Threshold or <br />Criteria: <br />2 87E <br />❑ Direct Bury ❑ Direct Bury <br />® Contained in Sump I ® Contained in Sump <br />3 91 <br />Direct Bury <br />Contained in <br />4 DSL <br />Direct Bury <br />Contained in <br />12 <br />12.25 <br />12 <br />14 <br />12 <br />12.75 <br />12 <br />13 <br />NA <br />NA <br />NA <br />NA <br />100 <br />100 <br />100 <br />100 <br />12 <br />13 <br />12 <br />12 <br />200 <br />200 <br />200 <br />200 <br />g <br />13 <br />12 <br />10 <br />1 HR <br />1 HR <br />1 HR <br />1 HR <br />0 <br />0 <br />0 <br />0 <br />1/16 <br />1/16 <br />1/16 <br />1/16 <br />Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />87 W & DSL BUCKET FAIL. NEEDS RINGS AROUND BUCKET <br />ELITE 4 WILL REPLACE AND RETEST <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: 7-9-09 <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 />