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REQRIVED <br />. <br />, January 2006 <br />Spill Bucket Testing Report Form OCT 14 2016 <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 the facility owner/operator for submittal tG'`�V j�f4MtW��/� <br />eLTH <br />1. FACILITY INFORMATION DEPARTMENT <br />Facility Name: FLAG CITY CHEVRON Date of Testing: 09-26-16 <br />Facility Address: 6421 CAPITAL LODI CALIFORNIA <br />Facility Contact: KfU Phone: 209-334-0975 <br />Date Local Agency Was Notified of Testing :09-13-16 <br />Name of Local Agency Inspector (fpresent during testing): SAN JOAQUIN CO <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: AFFORDA TEST 416 2"d 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 />II Credentials': ® ICC Service Tech. ® SWRCB Tank Tester 1I <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 />Nu;;zber, Stored Product, etc.) <br />1 87 <br />2 87 <br />3 91 <br />4 DIE <br />Bucket Installation Type: <br />Direct B <br />❑ ury <br />® Contained in Sump <br />El Bury <br />® Contained in Sump <br />❑Direct Bury <br />® Contained in <br />SumpSum <br />Direct Bury <br />® Contained in <br />Bucket Diameter: <br />1 1 <br />I 1 <br />11 <br />11 <br />Bucket Depth: <br />15 1,14 <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 />1250 <br />1250 <br />1250 <br />1250 <br />Initial Reading (Rj): <br />14 <br />14 <br />14 <br />14 <br />Test End Time (TF): <br />1350 <br />1350 <br />1350 <br />1350 <br />Final Reading (RF): <br />14 <br />14 <br />14 <br />14 <br />Test Duration (TF — Tj): <br />1 HOUR <br />20 MIN <br />1 HOUR <br />1 HOUR <br />Change in Reading (RF - Rj): <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 ❑ Fail <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 />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: 9-26-16 <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 />