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• • SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <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(ifapplicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1.FACILITY INFORMATION <br /> Facility Name: WEST LANE CHEVRON I Date of Testing: 9-25-17 <br /> Facility Address: 4747 WEST LANE STOCKTON, CA 95210 <br /> Facility Contact: Rinku Phone: 472-1639 <br /> Date Local Agency Was Notified of Testing: 9-13-17 <br /> Name of Local Agency Inspector(fpresent during testing): JOHN <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2nd Street Galt,CA 95632 (209)744-0112 Fax:(209)744-0116 <br /> Technician Conducting Test: ❑ Ed Stearns ❑ Zane A.Nimmo ® David A. Winkler ❑ Felix G. Ramirez <br /> 8184188 5263322-UT 5263373-UT 5273934-UT <br /> Credentials': ® ICC Service Tech. ® SWRCB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ®Hydrostatic ❑Vacuum ElOther <br /> Test Equipment Used: TAPE MEASURE, H2O Equipment Resolution: 1/16" <br /> Identify Spill Bucket (By Tank 1 91 2 87 MASTER 3 87 SLAVE 4 <br /> Number, Stored Product, etc.) <br /> Bucket Installation Type: El Direct Bury ❑Direct Bury <br /> El Direct Bury El Direct Bury <br /> ®Contained in Sump ® Contained in Sump ® Contained in El Contained in <br /> Sum Sum <br /> Bucket Diameter: 11 I1 11 <br /> Bucket Depth: 13 14 13 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 19 19 19 <br /> Initial Reading(R,): 12 1/2 13 1/2 13 <br /> Test End Time(TF): 11 1 I 11 <br /> Final Reading(RF): 12 1/2 13 1/2 13 <br /> Test Duration(TF—Ti): HR HR HR HR <br /> Change in Reading(RF-Rt): 0 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: ® Pass ❑ Fail ® Pass ❑ Fail ® Pass ❑ Fail ❑ Pass ❑ Fail <br /> Comments — (include information on repairs made prior to testing, and recommendedfollow-up for failed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the information contained in this report i accurate,and in full compliance with legal requirements. <br /> Technician's Signature . W <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 />