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MAY -23-2012 11:11 Service Station Systems 408 938 8885 P.06 <br />SWRCI3, 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 provid6d to the facility owner/operator for submittal to the local regulatory agency. <br />1 FA('Il ITV INFInRMATI()N <br />Facility Name' Chevron Date of Testing: 611/12 <br />Facility Address: 10858 Trinity Pkwy Stockton, CA 95219 - <br />Facility contact. Manager 209) 952-2213 <br />Date Local Agency Was Notified of Testing: J J <br />Name of Local Agency Inspector (if present during testing); <br />9 TF1ZTIN(: r(WTRAC`Tf)P INF(IRMATION <br />Company Name:Service Station Systems <br />Technician Conducting Test: Randy Wilkerson <br />Credentials:' Q CSLB Contractor [91 ICC Service Tech. ❑ SWRCS Tank Tester ❑ Other (Specify) <br />License Number(s)' License, 485184 ICC,5258560-UT <br />z CI?11 I R1I11%(FT TGCTINr. INF()RMATION <br />Test Method Used: []x Hydrostatic ❑ Vacuum Ej Other <br />Test Equipment Used: Measuring Tape Equipment Resolution.1 /16 In. <br />2 3 14 <br />❑ Direct Bury ❑ Direct Bury ❑ Direct Bury <br />Contained in Sump Contained in Sump ❑ Contained in Sump <br />Identify Spill Bucket (Sy Tank 1 Fill Bucket <br />Number, Stored Product, etc.) 01 Re U <br />Q Direct Bary <br />Bucket Installation Type: <br />® Contained in Sump <br />Bucket Diameter: <br />12.00 in. <br />Bucket Depth: <br />14.00 in. <br />Wait time between applying <br />vacuum/water and start of test: <br />5 min. <br />Test Start Time (TE )' <br />2,00pm <br />Initial Reading (R ): <br />13.500 in. <br />Test End Time (TF ): <br />3:00pm <br />Final Reading (F�, ): <br />13.500 in. <br />Test buration (TF - T 1): <br />1.00 hr. <br />Change in Reading (RF - R, ); <br />0-0000 in. <br />Fuss/Fail Threshold or Criteria: <br />ZERO LOSS <br />Comments: Replaced Bucket 0 -ring. Tested & Passed. <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:L—ILLL_Dated 5/1112 <br />I 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 />