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Spill Bucket Testing Report Form SWRCB,January 2006 <br /> This farm 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: TRACY BLVD CHEVRON I Date of Testing: 2-16-18 <br /> Facility Address: 3775 TRACY BLVD TRACY CA 95376 <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(ifpresent during testing): BETTY <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2n1 Street Galt,CA 95632 (209)744-0112 Fax:(209)744-0116 <br /> Technician Conducting Test: ❑ Lyle D.Nimmo ❑ Zane A.Nimmo N David A.Winkler ❑ Felix G.Ramirez <br /> 5249115-UT 5263322-UT 5263373-UT 5273934-UT <br /> Credentials': N ICC Service Tech. N SWRCB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: N Hydrostatic ❑vacuum ❑ Other <br /> Test Equipment Used: h20 and tape measure Equipment Resolution: 1/16 <br /> Identify Spill Bucket (By Tank 1 87 2 91 3 DSL 4 <br /> Number, Stored Product, etc. <br /> Bucket Installation T e: ❑Direct Bury ❑Direct B <br /> Direct Bury ❑Direct Bury <br /> YP � <br /> N Contained in Sump N Contained in Sump Su Contained in ❑ Contained in <br /> Sum Sum <br /> Bucket Diameter: 11 11 11 <br /> Bucket Depth: 12 12 12 <br /> Wait time between applying __ <br /> vacuum/water and start of test: <br /> Test Start Time(TI): 9 9 9 <br /> Initial Reading(Ri): I 1 1/2 11 11 <br /> Test End Time(TF): 10 10 10 <br /> Final Reading(RF): 11 1/2 11 11 <br /> Test Duration(TF—TI): IHR IHR IHR <br /> Change in Reading(RF-Rt): 0 0 0 <br /> Pass/Fail Threshold or 1/16 1/16 1/16 <br /> Criteria: <br /> Test Result: N Pass ❑Fail N Pass ❑ Fail 1 N Pass ❑Fail ❑ Pass <br /> ❑Fail <br /> Comments—(include information on repairs made prior to testing and recommendedfollow-up for failed tests) <br /> PT <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TF,STING <br /> 1 hereby certify that au the information contained in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: V 6-- ailDate 2-16-18 <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 />