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RE IV <br /> CB,January 2006 <br /> Spill Bucket Testing Report For#IC 13 2017 <br /> This form is intended for use btu contractors performing annual testing of USTspill containment structures. The completed form and <br /> printouts fi•onr tests(f applicable), should be provided to rhe Jacilin,ownerlovelq(q�Jc�{,SFr a ttgl, �f{�e�c�eg � tory agenct. <br /> 1. FACILITY INFORMATION 1VV �jUI lV'^H77%.iT <br /> Facility Names: Flag City Chevron Date of Testing: 12/12;2017 <br /> Facility Address: 6421 Capitol Ave Lodi,CA 95242 <br /> Facility Contact: Que Phone: 209-334-0975 <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: ELITE IV CONTRACTORS <br /> Technician Conducting Test: Chris Adams <br /> Credentials: ❑CSLB Contractor X ICC Service Tech. ❑SWRCB Tank Tester ❑Other(Specify) <br /> License Number(s): 8230218 11 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: X Hydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used: Equipment Resolution: <br /> Identify Spill Bucket (By Tank 1 87 --ly)C- f 2 3 4 <br /> Number, Stored Product, etc.) <br /> Direct Bury Direct Bury Direct Bury F-1DirectBury <br /> Bucket Installation Type: X Contained in Sump ❑Contained in Sump ❑Contained in Sump ❑Contained in Sum <br /> Bucket Diameter: 10" <br /> Bucket Depth: 15" <br /> Wait time between applying 10 Min <br /> vacuum/water and start of test: <br /> Test Start Time(Tj): 1220 <br /> Initial Reading(111): 14" <br /> Test End Time(TF): 120 <br /> Final Reading(RF): 14" <br /> Test Duration(TF—Ti): 1 Hr <br /> Change in Reading(RF-Rj): No <br /> Pass/Fail Threshold or Pass <br /> Criteria: <br /> Test Result: X Pass ❑Fail Pass ❑Fail Pass ❑Fail ❑ Pass ❑Fail <br /> Comments—(include information on repairs made prim to testing and recommended follow-tip for failed 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: ) Date: 12/12/17 <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 />