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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: KETTLEMAN CHEVRON Date of Testing: 7/22/2015 <br /> Facility Address: 601 E. KETTLEMAN LANE LODI, CA 95240 <br /> Facility Contact: TONY Phone: AMMI V Ammper..- <br /> Date Local Agency Was Notified of Testing:6/25/2015 J4, a I 20i5 <br /> Name of Local Agency Inspector(f present during testing): ARIS <br /> 2.TESTING CONTRACTOR INFORMATION :R., <br /> Company Name: AFFORDA TEST 416 2nd 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 5263371-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 MEASURE, H2O Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By Tank 1 87 2 87-2 3 91 4 DIESEL <br /> Number, Stored Product, etc. <br /> ®Direct Bury ®Direct Bury ®Direct Bury ❑Direct Bury <br /> [Bucket Installation Type: ❑ Contained in Sump ❑ Contained in Sump ❑Contained in ®Contained in <br /> Sum Sum <br /> Bucket Diameter: 11 11 11 11 <br /> Bucket Depth: 13 14 1/4 14 14 3/4 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(TI): 1311 1311 1200 1200 <br /> Initial Reading(RI): 11 1/2 12 3/4 13 13 1/4 <br /> Test End Time(TF): 1411 1411 1300 1300 <br /> Final Reading(RF): 11 1/2 12 3/4 13 13 1/4 <br /> Test Duration(TF—Tj): HR HR HR HR <br /> Change in Reading(RF-RI): 0 0 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> zest Re >rlt: I� F ® ❑ p F ® ❑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 '� Date: 7-22-15 <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 />