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• 0 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 (f applicable), should be provided to rhe facility owner/operator for submittal to the local regulatory agency. <br /> 1.FACILITY INFORMATION <br /> Facility Name: SHELL OIL TERMINAL Date of Testing: 10-6-2009 <br /> Facility Address: 3515 NAVY DR STOCKTON CA <br /> Facility Contact: <br /> Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(fpresent during testing): RAY <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 4162 nd Street Galt,CA 95632 (209)744-0112 Fax: (209)744-0116 <br /> Technician Conducting Test: Elm <br /> Lyle D.Nino ❑ Zane A.Nimmo ® David A. Winkler E] 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: 1120 & TAPE MEASURE Equipment Resolution: 1/16 <br /> Identify Spill Bucket(By Tank 1 SLOP TANK 2 3 4 <br /> Number, Stored Product, etc.) <br /> ❑ Direct Bury ❑Direct Bury <br /> ®Direct Bury ❑ Direct Bury ❑ Contained in ❑Contained in <br /> Bucket Installation Type: ❑ Contained in sump ❑Contained in Sump Sum Sum <br /> Bucket Diameter: 11 <br /> Bucket Depth: I I <br /> Wait time between applying NA <br /> vacuum/water and start of test: <br /> Test Start Time(Tj): 9AM <br /> Initial Reading(Ri): 10 <br /> Test End Time(TF): LOAM <br /> Final Reading(RF): 10 <br /> Test Duration(TF—Tj): 1 HR <br /> Change in Reading(RF-R): 0 <br /> Pass/Fail Threshold or 1/16 <br /> Criteria: <br /> Test Result: Pass ❑ Fail ❑ Pass ❑Fail ❑ Pass ❑Fail ❑ Pass ❑ Fail <br /> Comments— (include information on repairs made prior to testing, and recom, nded follow-up joriaued tests) <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: V ` — Date: 10-6-2009 <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 />