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ft <br />E, -1 <br />KK 11110, <br />E <br />'t S jVdd'hnuary 2006 <br />Spill Bucket Testing Report Form <br />' iTaI_ <br />This form is intended for use by contractors performing annual testing of UST spill containment struc and <br />rintouts om tests i a hcable should be provided to thefacility ownerlo erator or submittal Wkiibba re latory agency. <br />p .� C.% PP • I> P .f Y p f S� Y g Y• <br />1. FACILITY INFORMATION <br />Facility Name: CRM - PACIFIC AVE CHEVRON Date of Testing: 06-01-18 <br />Facility Address: 6633 PACIFIC AVE STOCKTON CA 95207 <br />Facility Contact: JOSH Phone: 916-947-1277 <br />Date Local Agency Was Notified of Testing: 12-26-17 <br />Name of Local Agency Inspector (if present during testing): SAN JOAQUIN CO STACI <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: AFFORDA TEST 416 2nd Street Galt, CA 95632 (209) 744-0112 Fax: (209) 744-0116 <br />Technician Conducting Test: ❑ Ed Stearns ❑ Zane A. Nimmo ❑ David A. Winkler ❑ Felix G. Ramirez <br />8883080 -UT 8883064 -UT 8883059 -UT 8883072 -UT <br />I Credentials': ® ICC Service Tech. ® SWRCB Tank Tester II <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: TAPE / H2O Equipment Resolution: <br />2 3 <br />4 <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 />F1 Direct Bury <br />❑ Contained in <br />E] Contained in Sump Sump <br />❑ Direct Bury <br />El Contained in <br />Sum <br />Bucket Diameter: <br />11 <br />Bucket Depth: <br />13 <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (Ti): <br />1100 <br />Initial Reading (Ri): <br />13 <br />Test End Time (TF): <br />1200 <br />Final Reading (RF): <br />13 <br />Test Duration (TF — TI): <br />1 HOUR <br />Change in Reading (RF - Ri): <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />Test Result: <br />® Pass ❑ Fail <br />❑ Pass ❑ Fail ❑ Pass ❑ Fail <br />❑ Pass ❑ Fail <br />Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />®PW 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: 1 Date:06-01-18 <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 />