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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: CHEVRON Date of Testing: 01-19-16 <br />Facility Address: 6633 PACIFIC AVE STOCKTON CA 95207 <br />Facility Contact: CRM I Phone: <br />Date Local Agency Was Notified of Testing :12-29-16 <br />Name of Local Agency Inspector (fpresent during testing): SAN JOAQUIN CO FEB 0 12016 <br />2. TESTING CONTRACTOR INFORMATION r=wyj9QNMENTAL <br />Company Name: AFFORDA TEST 416 211 Street Galt, CA 95632 (209) 744- I- M <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: ® Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: TAPE / H2O <br />Equipment Resolution: 1/16 <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, <br />1 87 <br />2 87 <br />3 91 <br />4 <br />Bucket Installation Type: <br />❑ Direct Bury <br />®Contained in Sump <br />❑ Direct Bury <br />®Contained in Sump <br />❑ Direct Bury <br />® Contained in <br />Sump <br />❑ Direct Bury <br />❑ Contained in <br />Sum <br />Bucket Diameter: <br />11 <br />11 <br />11 <br />Bucket Depth: <br />13 <br />13 <br />13 <br />Wait time between applying <br />vacuum /water and start of test: <br />Test Start Time (Ti): <br />1400 <br />1400 <br />1400 <br />Initial Reading (RI): <br />13 <br />13 <br />13 <br />Test End Time (TF): <br />1500 <br />1500 <br />1500 <br />Final Reading (RF): <br />13 <br />13 <br />13 <br />Test Duration (TF — Ti): <br />I hour <br />Ihour <br />1 hour <br />Change in Reading (RF - Rj): <br />0 <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />Test Result. <br />Pass ❑ Fail ; <br />0 <br />fl Fail <br />E] Pass <br />❑',Fail <br />Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />PHIL TITE <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:01-19-16 <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 />