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R698WED <br />Spill Bucket Testing Report FO%L2 3 2017 swxeB, January 2006 <br />This form is intended for use by contractors performing annual testing of UST spill contTH <br />RONMENTAL HEALres. The com leted orm and <br />�€ MW#E � P f <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: FLAG CITY CHEVRON Date of Testing: 9-26-17 <br />Facility Address: 6421 CAPITAL LODI CALIFORNIA 95242 <br />Facility Contact: KIU Phone: 209-334-0975 <br />Date Local Agency Was Notified of Testing: 8-24-17 <br />Name of Local Agency Inspector (f present during testing): SAN JOAQUIN CO <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: ❑ Ed Stearns ❑ Zane A. Nimmo ® David A. Winkler ❑ Felix G. Ramirez <br />8184188 -UT 8211269 - UT 5263373 -UT 5273934 -UT <br />Credentials': ® ICC Service Tech. ® SWRCB Tank Tester <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: ® I lydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: TAPE H2O <br />Equipment Resolution: 1/16 <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc. <br />1 87 master <br />2 87 <br />3 91 <br />4 DIE <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 />11 <br />Bucket Depth: <br />15 1/4 <br />14 <br />14 <br />15 1/2 <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (TI): <br />10 <br />10 <br />10' 1 <br />10 <br />Initial Reading (Ri): <br />14 <br />14 <br />14 <br />14 <br />Test End Time (TF): <br />11 <br />11 <br />11 <br />11 <br />Final Reading (RF): <br />13 <br />14 <br />14 <br />14 <br />Test Duration (TF — TI): <br />1 HOUR <br />20 MIN <br />1 HOUR <br />1 HOUR <br />Change in Reading (RF -Ri): <br />0 <br />0 <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />0 <br />0 <br />0 <br />0 <br />Test Result: <br />❑ Pass ® Fail <br />® Pass ❑ Pail <br />® Pass ❑ Fail <br />® Pass ❑ Fail <br />Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />OPW BUCKETS <br />87 Master failed — To be repaired and retested by others <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: W 9-26-17 <br />' State laws and regulations do not currently require testing to be performed by a qualified contractor. However, <br />local requirements may be more stringent. <br />