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r <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(tf applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: WEST LANE CHEVRON I Date of Testing: 9/19/2018 <br /> Facility Address: 4747 N.WEST LANE STOCKTON,C 2 <br /> Facility Contact: Phone: _ Lof <br /> Date Local Agency Was Notified of Testing:8/29/2018 <br /> Name of Local Agency Inspector(ifpresent during testing): STACY R. QCT ? 2�1 <br /> 2. TESTING CONTRACTOR INFORMATION 11RR� <br /> Company Name: AFFORDA TEST 416 2"d Street Galt,CA 956321744- -0116 <br /> Technician Conducting Test: ❑Ed Stearns ® Zane A.Nimmo ❑ David A.Winkler ❑ Felix G.Ramirez <br /> 8883080-UT 8883064-UT 8883059-UT 8883072-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, H2O Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By Tank 1 87 OCT - EAST 2 87 OCT - MID 3 91 4 <br /> Number, Stored Product, etc.) <br /> ❑Direct Bury ❑Direct Bury ❑Direct Bury ❑Direct Bury <br /> Bucket Installation Type: ® Contained in El Contained in <br /> ® Contained in Sump ® Contained in Sump SUMP Sum <br /> Bucket Diameter: 11 11 11 <br /> Bucket Depth: 13 15 14 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 1000 1158 1000 <br /> Initial Reading(RI): 13 - 14 - 14 - <br /> Test End Time(TF): 1100 1258 1100 <br /> Final Reading(RF): 13 - 14 - 14 - <br /> Test Duration(TF—TI): H O U R <br /> Change in Reading(RF-RI): 0 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: ® Pass ❑ Fail ® Pass ❑ Fail ® Pass ❑ Fail ❑ Pass ❑ Fail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> REPLACED DRAIN VALVE AND UPPER GASKET ON MIDDLE 87 TANK AND RETESTED WHILE INSPECTOR <br /> ON SITE. <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: 9/19/2018 <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 />