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"iy <br /> -D <br /> X <br /> '-"'-'SWRCB,January 2006 <br /> Spill Bucket Testing Report Form,,, <br /> DIN MWAENTAL <br /> This form is intended for use by contractors performing annual testing of UST spill cone se Winpletedform and <br /> printouts from tests(if applicable), should be provided to the facility ownerloperatorfor submittal to the local regulatory agency. <br /> 1.FACILITY INFORMATION <br /> -Facility Name: COLLIER ROAD CHEVRON I Date of Testing: 6/5/2018 <br /> -Facility Address: 25651 N.HIGHWAY 99 ACAMPO,CA 95220 <br /> -Facility Contact: Phone: <br /> -Date Local Agency Was Notified of Testing:5/23/2018 <br /> Name of Local Agency Inspector(ifpresent during testing): AARON <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2nd Street Galt,CA 95632 (209)744-0112 Fax:(209)744-0116 <br /> Technician Conducting Test: E]Ed Steams M Zane A.Nimmo F] David A.Winkler F] Felix G.Ramirez <br /> 8883080-UT 8883064-UT 8883059-UT 8883072-UT <br /> Credentials': 0 ICC Service Tech. SWRCB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: Z Hydrostatic F1 Vacuum 0 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. I <br /> 0 Direct Bury ❑Direct Bury E]Direct Bury 0 Direct Bury <br /> Bucket Installation Type: ® Contained in Sump F] Contained in Sump N Contained in X Contained in <br /> Sump Sump <br /> Bucket Diameter: 11 11 I I <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(Tj): 1045 1045 1220 <br /> Initial Reading(Ri): 10 1/4 10 1/2 11 - <br /> Test End Time(TF): 1145 1145 1320 <br /> -Final Reading(RF): 10 1/4 10 1/2 11 - <br /> Test Duration(TF—TI): HOUR HR HR <br /> Change in Reading(RF-RI): 0 0 0 <br /> Pass/Fail Threshold or <br /> -Criteria: <br /> Test Result: ®,Pass El Fail 0 Pass El Fail 0 Pass El Fail I Pass El Fail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> REPLACED DIESEL DRAIN VALVE, RETESTED AT TIME OF INSPECTION,PLACED IN SERVICE. <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: 6/5/2018 <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 />