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I <br />.l <br />s e ED <br />CB, January 2006 <br />Spill Bucket Testing Report Form <br />This form is intended for use by contractors performing annual testing of UST spill containme r t - rm and <br />printouts from tests (if applicable), should be provided to the facility owner/operator fo t e story agency. <br />I TM a l+TT TT%7 YATL`1'l1D1Ui A WIFAV <br />Facility Name: CRM -PACIFIC AVE CHEVRON Date of Testing: 1/23/2017 <br />Facility Address: 6633 PACIFIC AVE. STOCKTON , CA 95207 <br />Facility Contact: CRM Phone: 477-4294 <br />Date Local Agency Was Notified of Testing :12/28/2017 <br />Name of Local Agency Inspector (fpresent during testing): VICKIE <br />Company Name: AFFORDA TEST 416 2°a 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 />u Credentials': ® ICC Service Tech. ® SWRCB Tank Tester II <br />oeiTT T nTrn'L7 rr rrVQgrTN!'' YVVnDMArr1rnN <br />Test Method Used: ® Hydrostaticy Y v' ❑ Vacuum ❑ Other <br />Test Equipment Used: TAPE MEASURE, H2O Equipment Resolution: 1/16" <br />2 87-2 <br />❑ Direct Bury <br />®Contained in Sump <br />3 91 <br />Direct Bury <br />E]® Contained in <br />Sump <br />4 <br />F1 Direct Bury <br />E] Contained in <br />Sum <br />Identify Spill Bucket (By Tank 1 87 <br />Number, Stored Product, etc. <br />Bucket Installation Type: ❑ Direct Bury <br />®Contained in Sump <br />Bucket Diameter:11 <br />11 <br />11 <br />Bucket Depth: 13 <br />13 <br />13 <br />Wait time between applying _- <br />vacuum/water and start of test: <br />-- <br />-- <br />Test Start Time (Ti): 1400 <br />1400 <br />1400 <br />Initial Reading (Ri): 13 <br />13 <br />13 <br />est End Time (TF): <br />1500 <br />1500 <br />1500 <br />nal Reading (RF):13 <br />13 <br />13 <br />est Duration (TF — Ti): <br />r <br />HR <br />HR <br />HRHR <br />hange in Reading (RF - RI): <br />0 <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria <br />.�'t l�.esR� <br />®.: P..�ss: ❑ .Fail: <br />,Pass;' ❑Fail <br />-_ <br />'� Piss ❑ Fa�L <br />❑> � F�tl <br />Comments — (include information on repairs made prior to testing and recommenae!F jouow-up jur julieu beala j <br />BUCKETS MEASURED SHORT OF 5 GALLONS. APPROX. 1 GAL. LEFT. <br />THIS BUCKET SYSTEM HAS ZERO CHANCE OF SPLASH OUTSIDE THE <br />FILL SUMP, I BELIEVE THE FILL SUMP COULD BE SEEN AS PART OF <br />THE BUCKET WITH A SENSOR TO ALERT THE OPERATOR. <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: 1-23-17 <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 />