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09/18/2014 06:20 120933-4"-73 FLAGCITV CHEVRON PAGE 02/02 <br />Pogo r�r <br />S"WJRCB, January 2006 <br />Spill Bucket Testing Report Form <br />Msform is intended for use by cont[^actors performing annual testily of UST spill containment structures_ The completed form and <br />Printoutsfrom /Rate (if applicable), should be providad to the facility orfnterloperalorforsubmitW to the local r,vgulatory agency. <br />1. FACILITY INFORMATION <br />Facili Name; FLAG CITY CRF] VRON Date of Test' 09-04.13 <br />racility Address: 6421 CAPITAL L UDI CALIFORNIA <br />Facility contact: KIU Phone: 209-3340975 <br />T)Rte Local /agency Was Notified of Testing :8-13-13 <br />Name of Local Agency Inspector (if present dwtg tcsx#igk SAN JOA,QUIN CO <br />2. TESTING CONTRACTOR INFORMATION <br />Company Nine; AFF01ZDA TEST 416 2°`r StYeet Galt, CA 95632 (209) 744-0112 Fai: (209) 744-0116 <br />Technician Conducting Teat: 1-7 .Lyle D. Nimmo ❑ Gran A. Nimrno ® David A, Winlder ® Felix G, Ramircz <br />5249115-1.7T 5263322 -UT 5263373 -UT 5273934-LTT <br />Credentials': E ICC Service Tech ® SWRC'B Tank Tester <br />2 elmir Y nY'f1' v.. T rrr C'rr v N ... m <br />Test Method Used,. N FIydrostatic ^ ❑ Vacuum + ❑Other <br />Test EgtdpanentUsed: TAPE1d20 <br />Equipment Resolution: I/16 <br />Identify Spill 13ucket (By Tank <br />Nunsber, StoredProduct etrn <br />1 87 <br />2 87 <br />3 91 <br />4 DIE <br />Installation Type: <br />❑ Direct Bury <br />Contained in Sum <br />Sump <br />[� Uirect Bury <br />Contained in Stnnp <br />Dir-ecBucket <br />Conta . <br />®Coritain.ed in <br />Sump <br />Direct Bury <br />Contained in <br />Sum <br />Bucket Di,Rmetor: <br />11 <br />11 <br />11 <br />11 <br />Bucket Depth: <br />15 1/4 <br />14 <br />14 <br />1.5 112 <br />Wait time between, qpplying <br />vacuum/water and start of test; <br />- <br />- <br />Test Start Time (T=): <br />1100 <br />7.100 <br />1100 <br />1100 <br />T,nitial aading (KZ : <br />14 <br />:12 112 <br />14 <br />] 4 <br />I.Test Ttid Time (Ts): <br />1200 <br />1200 <br />1200 <br />1200 <br />Final /Reading (Rr): <br />14 <br />121/2 <br />14 <br />14 <br />Test Duration. (TY — TO: <br />1 HoLgt <br />I HOUR <br />I IIOUR <br />1 HOUR <br />Charge in Reading (ERF- TRi): <br />0 <br />0 <br />0 <br />0 <br />J?Rss/Fail Threshold or <br />Ciiteria: <br />0 <br />0 <br />0 <br />U <br />a h� <br />4 fill <br />:.i 1f? <br />%.vmmmenzg — (tnOMMI irrlormation on repairs made p)Ior to testuxe and maomrnendedfollow-up orBled tests} <br />QPW RUCKE15 <br />CERTII+ICATION OF TECHNICIAN RNSPO]NSIALE FOR CONDUCTT.NC; THIS TOTING <br />I herehy "Alty that all the In'forination contained In thtl report is hme, accurate, aqd In Bill cotmpllance with le al Mqulrenn arts. <br />Technician's Signature:_ {' " Date; X41,3 <br />i State law% and rogulations donot. currently squire testing to be performed by a gtutl,ified contractor, However, ].peal roquitements <br />may be more stringent. <br />