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06/18/2013 11:36AM FAX 2093330318 KSN CORP <br />SN <br />Spill Bucket Testing Report Form <br />This form iy intended for ime by contractors performing annuoltesting of MT spill containment structures. he <br />prinioursfrnm tests (afapplicable), should be provided to the faculty ownarloperatorfor submittal to the local r <br />I. FACIUTY INFORMATION <br />a 0006/0006 <br />FacilityName: COLLIER CHEVRON D 1 11 <br />--2!! of Testin- 6/11/1 <br />s <br />Facilitz Address: 25651 N HWY 99 ACAMP0,- CA 95220 <br />Facility Contact: TONY <br />Date Local Agency Was Notified of Testing :5/15/13 <br />Name of Local Aw-ency Insocaor (if resent durini, la-viiniz): ARTS <br />January 2006 <br />Iform and <br />agency. <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TuTING <br />I hereby certify that all the information contained in this report is true, accurate, and in full compliance with Iepl requirements. <br />Technician's Signature Dute:—'- 6-11.13 <br />State laws and regulations do not currently require testing to be performed by a qualified contractor. However, loco requirements <br />may be more stringent. I <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: AFFORDA TEST 416 2ad Street Galt, CA 95632 <br />(209) 744-011 Fax- (20 11) 744-0116 <br />Technician Conducting Tc -A' <br />Lyle D, Nimmo 0 Zane A, Nimmo [3 David A. Winkler Felix G. Rai <br />*ez <br />5249115 -UT 5263322 -UT <br />5263373 -UT 5273934-I'T <br />Credentials': ICC Service Tech. SWRCB Tank Tester <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: <br />Hydrostatic ❑ vacuum <br />Other <br />Test Equipment Used: TAPF MEASURE, 1120 <br />Equipment Resolution: 1116" <br />Identify Spill Bucket (By Tank <br />OEM= <br />1 87 2 <br />3 91 4 DIES <br />Number, Stored Product, etc.) <br />-7 <br />TL <br />Bucket Installation Type: <br />0 Direct Bury Direct Bury <br />Direct Bu =D' <br />Bury ��5 on <br />[9 Contained in tog con <br />Bury <br />24 <br />inedlin <br />Contained in Sump Contained in Sump <br />Sump SUME <br />Bucket Diameter: <br />11 <br />I I <br />Bucket Depth, <br />12 1/2 <br />13 1/2 12 3/4 <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (Tl): <br />1245 <br />1245 1245 <br />Initial Reading (R.1): <br />11 3/4 <br />12 1/2 12- <br />Toi,t End Time (TO: <br />1345 <br />1 345 1345 <br />Final Reading (RF): <br />11 3/4 <br />12 1/2 12- <br />Test Duration (TF - Tj): <br />HR <br />FIR HR <br />Change in Reading (Rp - R,): <br />0 <br />0 tl <br />Pass/Fail Threshold or <br />Criteria, <br />Comments - include kmation on Mairs madeprior to tem and recommended allow-tt orklad lests2 <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TuTING <br />I hereby certify that all the information contained in this report is true, accurate, and in full compliance with Iepl requirements. <br />Technician's Signature Dute:—'- 6-11.13 <br />State laws and regulations do not currently require testing to be performed by a qualified contractor. However, loco requirements <br />may be more stringent. I <br />