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� e <br /> 1• <br /> 7 <br /> +1 4i <br /> JUL 5 X016 , <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 /> I.FACILITY INFORMATION <br /> Facility Name: COLLIER RD CHEVRON Date of Testing: 6/17/16 <br /> Facility Address: 25651 N HWY 99 ACAMPO,CA <br /> Facility Contact: Phone: 209-333-0305 <br /> Date Local Agency Was Notified of Testing:6/15/16 <br /> Name of Local Agency Inspector(afpresent during testing): <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: ®Ed Stearns ❑Lyle D.Nimmo ❑ Zane A.Nimmo <br /> ❑ David A.Winkler ❑ Felix G. Ramirez <br /> 5250492-UT 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 MEASURE Equipment Resolution: 1/16 <br /> Identify Spill Bucket(By Tank 1 87 2 91 3 DIE 4 <br /> Number, Stored Product, etc. <br /> ❑Direct Bury ❑Direct Bury Direct Bury Fj Direct Bury <br /> Bucket Installation Type: <br /> ®Contained in Sump ®Contained in Sump ®Contained in El Contained in <br /> Sum Sum <br /> Bucket Diameter: 11 11 11 <br /> Bucket Depth: 12 12 12 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 1045 1045 1045 <br /> Initial Reading(RI): 12 12 12 <br /> Test End Time(TF): 1145 1145 1145 <br /> Final Reading(RF): 12 12 12 <br /> Test Duration(TF—Tj): IHR IHR IHR <br /> Change in Reading(RF-Ri): 0 0 0 <br /> Pass/Fail Threshold or 1/16 1/16 1/16 <br /> Criteria: <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:1 ti�?44Lz Date:6/17/16 <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 />