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pnmm% . <br />SWRCB�January 2,0,06 <br />Spill Bucket Testing Report Form T c� A <br />This form is intended for use by contractors performing annual testing of UST spill containment structuroe� TTS l 0,%d form and <br />printouts from tests (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1 FACTT.TTV INFORMATION ENVIRONMENTAL HEALTH <br />Facility Name: FLAG CITY CHEVRON Date of Testing: <br />Facility Address: 6421 CAPITAL LODI CALIFORNIA <br />Facility Contact: K1U Phone: 209-334-0975 <br />Date Local Agency Was Notified of Testing :8-25-14 <br />Name of Local Agency Inspector (fpresent during testing): SAN JOAQUIN CO <br />2. TESTING CONT RAC1 OR INPORIVIA I IU1N <br />Company Name: AFFORDA TEST 4162 nd 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 />Credentials': ® ICC Service Tech. ® SWRCB Tank Tester I <br />I QPII I III ICKFT TFQ%TINC. INFORMATION <br />Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: TAPE H2O Equipment Resolution: 1/16 <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />1 87 <br />2 91 <br />3 87 <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 />_ <br />- <br />_ <br />_ <br />Test Start Time (Tj): <br />1 100 <br />1100 <br />1100 <br />1100 <br />Initial Reading (Rj): <br />14 <br />14 <br />14 <br />14 <br />Test End Time (TF): <br />1200 <br />1120 <br />1200 <br />1200 <br />Final Reading (RF): <br />14 <br />10 <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 -Ri): <br />0 <br />4 <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 informulion on repairs mxadc prior to testing, and recommended li)llou -up Jor- /aile(l tests) <br />OPW BUCKETS <br />CRACK IN 91 BUCKET, 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:_ t I — Date: -9-24-14 <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 />