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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 (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: CHEVRON 307709 1 Date of Testing: 3/24/2017 <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): ceaser r <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: TANKNOLOGY INC. MAR 29P <br />Technician Conducting Test: Steve Willems <br />Credentials): W CSLB Contractor F ICC Service Tech. r SWRCB Tank Tester r Other (Specify) <br />License Number(s): A LJIVIROMM— <br />VL{ 1INI S I IV1"1141 <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used By: r Hydrostatic r vacuum F Other <br />Test Equipment Used: LAKE TEST Equipment Resolution: 0.0625 in. <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 />PREMUM - Fill 1 - Direct - <br />Grade level in containment <br />sump <br />Spill Box # Tank T-2 <br />PREMIUM - Fill I - 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 />Bucket Installation Type: <br />C Direct Bury <br />r; Contained in Sump <br />r Direct Bury <br />Contained in Sump <br />r Direct Bury <br />R Contained in Sump <br />{ Direct Bury <br />Contained in Sump <br />Bucket Diameter: <br />12.00 <br />12.00 <br />12.00 <br />12.00 <br />Bucket Depth: <br />12.50 <br />12.50 <br />12.50 <br />12.50 <br />Wait time between applying <br />vacuum/water and start of test <br />5 min <br />5 min <br />1 min <br />5 min <br />Test Start Time (Tl): <br />13:02:00 <br />13:02:00 <br />15:26:00 <br />13:02:00 <br />Initial Reading (Rl): <br />12.25 in. H2O <br />12.00 in. H2O <br />30.00 in. HG <br />12.25 in. H2O <br />Test End Time(TF): <br />14:02:00 <br />13:47:00 <br />15:27:00 <br />14:02:00 <br />Final Reading (RF): <br />12.25 in. H2O <br />11.50 in. H2O <br />30.00 in. HG <br />12.25 in. H2O <br />Test Duration(TF—Tl): <br />1 hr <br />45 min <br />1 min <br />I hr <br />Change in Reading (RF—Rl) : <br />0.00 in. H2O <br />-0.50 in. H2O <br />0.00 in. HG <br />0.00 in. H2O <br />Pass/Fail Threshold or Criteria: <br />+/-0.00 <br />+/-0.00 <br />+/-4.00 <br />+/-0.00 <br />Test Result: <br />Pass <br />Fail <br />Pass <br />Pass <br />Comments - (include information on repairs made prior to testing, and reconsmended follow-up for failed tests) <br />replaced the drain and shut off ring on the 91 fill, spill buckets pass tightness but not capacity. <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: 3/24/2017 <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: 2330296 <br />