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b <br />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 1VAf 7T T'TV TVVn12X4AT1nN <br />Facility Name: COLLIER RD. CHEVRON Date of Testing: 6/15/10 <br />Facility Address: 25651 N. HWY 99 ACAMPO, CA 95220 <br />Facility Contact: TONY <br />Phone: 209-333-1740 _ <br />Date Local Agency Was Notified of Testing :6/3/10 <br />Name of Local Agency Inspector (rf present during testing): ARIS CACAPIT <br />2_ TFRTING 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 1 <br />5249115 -UT 5263322 -UT 5263373 -UT 5273934 -UT <br />11 Credentials': ® ICC Service Tech. ® SWRCB Tank Tester J <br />z enTT T RTrf''TIFT'rFCTTNr INW-MMATION <br />Test Method Used: ® HydrostaticY _ 0 Vacuum ❑ Other <br />Test Equipment Used: TAPE MEASURE, <br />H2O <br />Equipment Resolution. 1/16" —� <br />2 <br />❑ Direct Bury <br />( Contained in Sump <br />3 91 <br />❑ Direct Bury <br />® Contained in <br />Sump <br />4 DIESEL <br />❑ Direct Bury <br />® Contained in <br />Sum <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />Bucket Installation Type: <br />1 87 <br />❑ Direct Bury <br />® Contained in Sump <br />Bucket Diameter: <br />11 <br />I I <br />I I <br />Bucket Depth: <br />13 <br />13 <br />13 <br />Wait time between applying <br />vacuum/water and start of test: <br />_ <br />__ <br />-- <br />Test Start Time (Ti): <br />1 125 <br />1 125 <br />1125 <br />Initial Reading (Rj): <br />12 1/8 <br />125/8 <br />12 1/2 <br />Test End Time (TF): <br />1225 <br />1225 <br />1225 <br />Final Reading (RF): <br />12 1/8 <br />10 1/8 <br />121/2 <br />Test Duration (TF — Ti): <br />HR <br />HR <br />HR <br />Change in Reading (RF- RI): <br />0 <br />-2 1/2 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />_ <br />-- <br />-- <br />Test Result: <br />®Pass ❑ Fail ' <br />=, Pass ❑ Fail <br />❑ Pass Z Fail <br />Pass El Fail <br />Comments — (include information on repairs made prior to testing and recommended follow-up for jailed tests) <br />FOUND THE 91 SPILL BUCKET DRAIN HAS GONE BAD. UNABLE TO REPAIR. SITE MUST GET A PERMIT AND <br />A CONTRACTOR TO MAKE REPAIRS TO 91 SPILL BUCKET. <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:6/15/10 <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 />