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i _.=CEIVED <br />FEB 0 2 2016VRCB, January 2006 <br />Spill Bucket Testing Report Form <br />This form is intendedfor use by contractors performing annual testing of UST spill containrn);NV 699NWWAlompleted form and <br />printouts from tests (if applicable), should be provided to the facility owner/operator for Ai 1WTADGPA 32FMF;NT7tory agency. <br />1. FACILITY INFORMATION <br />Facility Name: WEST LANE CHEVRON I Date of Testing: 09-29-15 <br />Facility Address: 4747 N WEST LANE STOCKTON CA 95210 <br />Facility Contact: RAVINDER Phone: 209-472-1639 <br />Date Local Agency Was Notified of Testing :09-22-15 <br />Name of Local Agency Inspector (f present during testing): SAN JOAQUIN CO <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: AFFORDA TEST 4162 "d 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 />I Credentials': ® ICC Service Tech. ® SWRCB Tank Tester <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: TAPE / H2O <br />Equipment Resolution: 1/16 <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />1 87 <br />2 87 <br />3 91 <br />4 <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 />El Contained in <br />Sum <br />Bucket Diameter: <br />11 <br />11 <br />11 <br />Bucket Depth: <br />13 <br />13 <br />13 <br />Wait time between applying <br />vacuum/water and start of test: <br />- <br />- <br />Test Start Time (TI): <br />9000 <br />900 <br />900 <br />Initial Reading (RI): <br />12 <br />12 <br />12 <br />Test End Time (TF): <br />1000 <br />1000 <br />1000 <br />Final Reading (RF): <br />12 <br />12 <br />12 <br />Test Duration (TF — Tj): <br />I HOUR <br />1 HOUR <br />1 HOUR <br />Change in Reading (RF -Rj): <br />0 <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />Test Result: <br />® Pass ❑ Fail <br />® Pass ❑ Fail <br />® Pass ❑ Fail <br />❑ Pass ❑ Fail <br />Comments — (include information on repairs made prior to testing, and recommended folloiv-up for failed tests) <br />OPW BUCKETS <br />CERTIFICATION OF TECHMCIAN RESPONSIBLE FOR CONDUCTING TATS TESTING <br />I hereby certify that all the information contained in this report is true, accurate, and in full compliance with legal requirements. <br />11 <br />Technician's Signature: Date:09-29-15 <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 />