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SB J.!'yh <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 formAgy 1 1 2016 <br />printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatf f—tNMENT L <br />1. FACILITY INFORMATION ,,,�,A[TH FiPP60 -. , -_, .. _. <br />Facility Name: CHEVRON 307709 Date of Testing: 3/31/2016 <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 of Local Agency Inspector (if present during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: TANKNOLOGY INC. <br />Technician Conducting Test: Jarrod Cooke <br />Credentials): n CSLB Contractor r 1CC' Srn icr'I ch. r SU'RCB Tank Tester M Other (Specify) <br />License Number(s): 8155550 <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used By: r-1 Hydrostatic R-6 Vacuum I . ! 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 Tl <br />UNLEADED - Fill 1 - Direct <br />- Grade level in <br />containment sump <br />Spill Box # Tank T-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 />Direct Bury <br />(: Contained in Sump <br />% Direct Bury <br />Q Contained in Sump <br />td Direct Bury <br />9 Contained in Sump <br />f Direct Bury <br />(' 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 (Tl): <br />09:38:00 <br />09:42:00 <br />09:45:00 <br />Initial Reading (Rl): <br />30.00 in. H2O <br />30.00 in. H2O <br />30.00 in. H2O <br />Test End Time(TF): <br />09:39:00 <br />09:43:00 <br />09:46:00 <br />Final Reading (RF): <br />26.00 in. H2O <br />28.00 in. H2O <br />29.00 in. H2O <br />Test Duration(TF-T,): <br />I min <br />1 min <br />1 min <br />Change in Reading (RF -RI) : <br />4.00 in. H2O <br />-2.00 in. H2O <br />-1.00 in. H2O <br />Pass/Fail Threshold or Criteria: <br />+/-4.00 <br />+/-4.00 <br />+/-4.00 <br />fest 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: C/v <br />Date: 3/31/2016 <br />'State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more stringent. <br />WO: 2326243 <br />