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Spill Bucket Testing Report Form J ftary 2006 This form is intended for use by contractors performing annual testing of UST spill containment structure,. The +welted form and printouts from tests (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION 2. TESTING CONTRACTOR INFORMATION Company Name: AFFORDA TEST 416 2nd Street Galt, CA 95632 (209) 744-0112 Fax: (209) 744-0116 Technician Conducting Test: ❑ Lyle D. Nimmo ❑ Zane A. Nimmo ® David A. Winkler ❑ Felix G. Ramirez 5249115 -UT 5263322 -UT 5263373 -UT 5273934 -UT Credentials': ® ICC Service Tech. ® SWRCB Tank Tester 3. SPILL BUCKET TFSTINC' INFORMATION Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other Facility Name: HAMMER LANE OIL CHEVRON Date of Testing: 6-13-2016 Equipment Resolution: 1/16 Facility Address: 3304 W HAMMER LANE STOCKTON CA Facility Contact: I Phone: 1 87 Date Local Agency Was Notified of Testing :5-24-16 3 DSL Name of Local Agency Inspector (if present during testing): FATINA 2. TESTING CONTRACTOR INFORMATION Company Name: AFFORDA TEST 416 2nd Street Galt, CA 95632 (209) 744-0112 Fax: (209) 744-0116 Technician Conducting Test: ❑ Lyle D. Nimmo ❑ Zane A. Nimmo ® David A. Winkler ❑ Felix G. Ramirez 5249115 -UT 5263322 -UT 5263373 -UT 5273934 -UT Credentials': ® ICC Service Tech. ® SWRCB Tank Tester 3. SPILL BUCKET TFSTINC' INFORMATION Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other Test Equipment Used: h20 and tape measure Equipment Resolution: 1/16 Identify Spill Bucket (By Tank Number, Stored Product, etc. 1 87 2 91 3 DSL 4 Bucket Installation Type: ® Direct Bury El Contained in Sump ® Direct Bury El Contained in Sump ® Direct Bury El Contained in Sump ❑ Direct Bury El Contained in Sum Bucket Diameter: 11 11 11 Bucket Depth: 14 14 14 Wait time between applying vacuum/water and start of test: Test Start Time (Ti): 2 2 2 Initial Reading (Rj): 13 12.50 13 Test End Time (TF): 3 3 3 Final Reading (RF): 13 12.50 13 Test Duration (TF — TI): IHR IHR IHR Change in Reading (RF - RI): 0 0 0 Pass/Fail Threshold or Criteria: 1/16 1/16 1/16 Test Result: ®Pass ' ❑ Fail' ` Pass ' ! ❑Fail Pass ❑Fail : E -,--Pass . ,❑ Fail Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING I hereby certify that all the information contained in this report is true, accurate, and in full compliance with legal requirements. It I Technician's Signature: Date 6-13-2016 ' State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more stringent.