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Spill Bucket Testing Report Form R�MIVEt <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 (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory ageAFR 3 0 2015 <br />1. FACILITY INFORMATION ENVIHL <br />Facility Name: CHEVRON 307709 Date of Testing:4/15/201$-!7A' 7-! ^.TroIS oT1At:.1 <br />Facility Address: 10858 TRINITY PKWY, STOCKTON, CA 95219 <br />Facility Contact:MANAGER (N-7462-1-10) Phone: 209-952-2213 <br />Date Local Agency Was Notified of Testing: <br />=Name Local Agency Inspector (if present during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: TANKNOLOGY INC. <br />Technician Conducting Test: Jarrod Cooke <br />Credentialsl : r CSLB Contractor V ICC Service Tech. r SWRCB Tank Tester r Other (Specify) <br />License Number(s):5311523 <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used By: r Hydrostatic 171 Vacuum r— Other <br />Test Equipment Used: VACUUM TEST Equipment Resolution: 0.1 gph <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />Spill Box #Tank T1 <br />UNLEADED - Fill 1 - Direct <br />- Grade level in <br />containment sump <br />Spill Box #'funk I'-2 <br />PREMIUM - Fill 1 - Direct - <br />Grade level in containment <br />sump <br />Spill Box #"Tank T-3 Diesel <br />- Fill 1 - Direct - Grade level <br />in containment sump <br />Spill Box # <br />Bucket Installation Type: <br />r Direct Bury <br />to Contained in Sump <br />f"' Direct Bury <br />0 Contained in Sump <br />r Direct Bury <br />ro Contained in Sump <br />f' Direct Bury <br />r Contained in Sump <br />Bucket Diameter: <br />12.00 <br />12.00 <br />12.00 <br />Bucket Depth: <br />12.50 <br />12.50 <br />12.50 <br />Wait time between applying <br />vacuum/water and start of test <br />0 min <br />0 min <br />0 min <br />min <br />Test Start Time (TI): <br />09:36:00 <br />09:39:00 <br />09:44:00 <br />Initial Reading (RI): <br />30.00 in. H2O <br />30.00 in. H2O <br />30.00 in. H2O <br />Test End Time(TF): <br />09:37:00 <br />09:40:00 <br />09:45:00 <br />Final Reading (RF): <br />26.00 in. H2O <br />30.00 in. H2O <br />30.00 in. H2O <br />Test Duration(TF—T,): <br />1 min <br />I min <br />1 min <br />Change in Reading (RF—R1): <br />4.00 in. H2O <br />0.00 in. H2O <br />0.00 in. H2O <br />Pass/Fail Threshold or Criteria: <br />+/-4.00 <br />+/-4.00 <br />+/-4.00 <br />Test Result: <br />Pass <br />Pass <br />Pass <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�11�---- Date: 4/15/2015 <br />1State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more stringent. <br />WO: 2322112 <br />L <br />