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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(f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1.FACILITY INFORMATION <br /> Facility Name: LOWER CHEVRON I Date of Testing: 10-16-14 <br /> Facility Address: 8660 LOWER SAC RD STOCKTON CA <br /> Facility Contact: KAMAL Phone: 209-477-2844 <br /> Date Local Agency Was Notified of Testing:9-30-14 <br /> Name of Local Agency Inspector(f present during testing): SAN JOAQUIN CO <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 4162 nd Street Galt,CA 95632 (209)744-0112 Fax:(209)744-0116 <br /> Technician Conducting Test: ❑ Lyle D.Nimmo ❑ Zane A.Nimmo ❑ David A.Winkler E Felix G.Ramirez <br /> 5249115-UT 5263322-UT 5263373-UT 5273934-UT <br /> Credentials: E ICC Service Tech. ® SWRCB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: E Hydrostatic ❑Vacuum ❑ Other <br /> Test Equipment Used: TAPE/H2O Equipment Resolution: 1/16 <br /> Identify Spill Bucket(By Tank 1 87 2 89 3 91 4 <br /> Number, Stored Product, etc. <br /> Direct Bury ❑Direct Bury <br /> Bucket Installation Type: ®Direct Bury E Direct Bury ❑ Contained in ❑ Contained in <br /> El Contained in Sump ❑Contained in Sump Sump Sump <br /> Bucket Diameter: 11 11 11 <br /> Bucket Depth: 13 13 13 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 1330 1330 1330 <br /> Initial Reading(Ri): 12 12 1/2 12 <br /> Test End Time(TF): 1430 1430 1430 <br /> Final Reading(RF): 12 121/2 12 <br /> Test Duration(TF—Ti): 1 HOUR 1 HOUR 1 HOUR <br /> Change in Reading(RF-RI): 0 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: E Pass ❑Fail ® Pass ❑Fail E Pass ❑Fail ❑ Pass ❑Faii <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> OPW BUCKETS <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 /> n <br /> Technician's Signature: 0 Date:10-16-14 <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 />