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R*CEIVED <br /> >. <br /> WRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intended for use by contractors performing annual testing of UST spill cont NTA &pleted form and <br /> printouts from tests (f applicable), should be provided to the facility owner/operator for subSEMMERAWASegulatory agency. <br /> 1.FACILITY INFORMATION <br /> Facility Name: WILSON WAY CHEVRON I Date of Testing: 2-27-2017 <br /> Facility Address: 437 WILSON WAY STOCKTON CA 94205 <br /> Facility Contact: AMAD Phone: 209-942-2344 <br /> Date Local Agency Was Notified of Testing:1-30-17 <br /> Name of Local Agency Inspector(fpresent during testing): SAN JOAQUIN CO ELENA <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 ❑ Felix G. Ramirez <br /> 5249115-UT 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 ❑ Other <br /> Test Equipment Used: TAPE/H2O Equipment Resolution: 1/16 <br /> 77=7-79r�7177777 M7 <br /> Identify Spill Bucket(By Tank 1 87 2 91 3 4 <br /> Number, Stored Product, etc) <br /> ❑Direct Bury ❑ Direct Bury ❑ Direct Bury ❑ Direct Bury <br /> Bucket Installation Type: El Contained in F-1 Contained in <br /> ®Contained in Sump ® Contained in Sump Sump Sump <br /> Bucket Diameter: 11 11 <br /> Bucket Depth. 13 13 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 1013 9 <br /> Initial Reading(R,): 12 12 <br /> Test End Time(TF): 1114 10 <br /> Final Reading(RF): 12 12 <br /> Test Duration(TF—Ti): 1 HOUR 1 HOUR <br /> Change in Reading(RF-RI): 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Resl �t: Pass Q Fail 1 ® Pass ❑Fair ❑ Pass ❑Fail ❑ Pass ❑',Fail <br /> Comments— (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> CNI 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 /> Technician's Signature: . Date:02-27-17 <br /> ' State laws and regulations do not currently require testing to be performed by a qualified contractor.However, <br /> local requirements may be more stringent. <br />