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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 (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: COLLIER CHEVRON I Date of Testing: 06-14-11 <br />Facility Address: N HWY 99 ACAMPO CALIFORNIA 95220 <br />Facility Contact: TONY Phone: <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (f present during testing): SAN JOAQUIN CO ARIS <br />2. TESTING 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 />Credentials': ® ICC Service Tech. ® SWRCB Tank Tester <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: <br />® Hydrostatic <br />❑ Vacuum <br />❑ Other <br />Test Equipment Used: TAPE / H2O <br />Equipment Resolution: <br />1/16 <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc. <br />Bucket Installation Type: <br />1 87 <br />❑ Direct Bury <br />®Contained in Sump <br />2 91 <br />E] Direct Bury <br />®Contained in Sump <br />3 DIE <br />Fj Direct Bury <br />® Contained in <br />Sump <br />4 <br />El Direct Bury <br />F-1 Contained in <br />Sum <br />Bucket Diameter: <br />11 <br />11 <br />11 <br />Bucket Depth: <br />14 <br />14 <br />14 <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (TI): <br />1200 <br />1200 <br />1200 <br />Initial Reading (Rj): <br />13 <br />13 <br />13 <br />Test End Time (TF): <br />1300 <br />1300 <br />1300 <br />Final Reading (RF): <br />13 <br />13 <br />13 <br />Test Duration (TF - TI): <br />1 HOUR <br />i HOUR <br />1 HOUR <br />Change in Reading (RF - RI): <br />0 <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />_ <br />Test Result: <br />11;a °" r] Fail , ' <br />�( Pass. ;Q Fail i <br />Pass ❑Fail ., ❑ Pass ❑ Fail'. <br />Comments - (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />PHIL TITE BUCKETS <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:06-14-11 <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 />