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7 <br /> 0 0 SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intended for use by contractors performing annual testing of UST spall 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: COLLIER CHEVRON Date of Testing: 6/14/12 <br /> Facility Address: 25651 N HWY 99 ACAMPO, CA 95220 <br /> Facility Contact: TONY Phone: <br /> Date Local Agency Was Notified of Testing:5/24/12 <br /> Name of Local Agency Inspector(tfpresent during testing): ARIS CACAPIT <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 /> Credentials': ® ICC Service Tech. ® SWRCB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ® Hydrostatic El Vacuum Other <br /> Test Equipment Used: TAPE MEASURE, H2O Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By Tank 1 87 2 3 91 4 DIESEL <br /> Number, Stored Product, etc. <br /> r ❑Direct Bury ❑Direct Bury <br /> Direct Bury Direct Bury <br /> il c3ucket Installation Type: ® Contained in ®Contained in <br /> ® Contained in Sump ❑ Contained in Sump Sump Sum <br /> 3ucket Diameter: 11 11 11 " <br /> Bucket Depth: 12 1/2 13 1/2 12 3/4 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(TI): 0840 0840 0840 <br /> Initial Reading(Ri): 11 5/8 12 1/4 11 5/8 <br /> Test End Time(TF): 0940 0940 0940 <br /> Final Reading(RF): 11 5/8 12 1/4 11 5/8 <br /> Test Duration(TF—Tj): HR HR HR HR <br /> Change in Reading(RF-Ri): 0 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Resit: <br /> Dass Faux Piss: Fail Pass .(Dail : Pass, ❑Fail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-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 is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature -=' Date: 6-14-12 <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 />