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p <br /> nuary 2006 <br /> r PVE <br /> Spill Bucket Testis Report F <br /> This form is intended for use by contractors pei forming annual testing ol'UST spill containment strjiquresl 7� &W pleted form and <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 Names: Flag City ChevronDa 017 <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(Spec) <br /> License Number(s): 8230218 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: X Hydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used: I Equipment Resolution: <br /> Identify Spill Bucket(By Tank 187 2 3 4 <br /> Number,Stored Product, etc. <br /> Bucket Installation Type: Direct Bury Direct Bury Direct Bury ❑Direct Bury <br /> 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(Ti): 1220 <br /> Initial Reading(Ri): <br /> 14" <br /> Test End Time(TF): 120 <br /> Final Reading(RF): <br /> 14" <br /> Test Duration(TF—Ti): I 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 prior to testing and recommended follow-up for failed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> 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 />