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SWRCB, January 2006 <br />Spill Buckelt 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 fa ility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: CHEVRON 210997 (N-4693) Date of Testing: 1/21/2016 <br />Facility Address: 1442A COLONY DR., RIPON, CA 95366 <br />Facility Contact: PATTY Phone: 209-599-0149 <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (ifpreseni during testing): <br />2. TESTING CONTRACTOR INFORMATION FFR 2 2 2MG <br />Company Namc: TANKNOLOGY INC. <br />Technician Conducting Test: Jarrod Cooke ENVIHONMEN <br />HF,OITN nFPA... <br />CSLB Contractor C Service Tech. (Specify) SWRCB Tank Tester ❑ Other' <br />Credentials r 71 IC <br />License Number(s): 8155550 <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used By: r I lydrostatic r vacuum r. i Other <br />Test Equipment Used: VPLT Equipment Resolution: 0.00001 in. <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />Spill Box # Tank <br />T1:SUPREME UNLEADED <br />PREMIUM-FiIII-Direct- <br />Grade level in containment <br />sum <br />Spill Box tt Tank <br />T2:REGULAR UNLEADED <br />REGULAR-FiIII-Direct- <br />Grade level in containment <br />sum <br />Spill Box # <br />Spill Box# <br />Bucket Installation Type: <br />F'"� Direct Bury <br />r Contained in Sump <br />0 Direct Bury <br />OF Contained in Sump <br />(3 Direct Bury <br />9 Contained in Sump <br />r Direct Bury <br />IT Contained in Sump <br />Bucket Diameter: <br />12.00 <br />12.00 <br />Bucket Depth: <br />12.50 <br />12.50 <br />Wait time between applying <br />vacuum/water and start of test <br />min <br />min <br />5 min <br />5 min <br />Test Start Time (TI): <br />09:11:00 <br />09:14:00 <br />Initial Reading (RI): <br />30.00 in. H2O <br />30.00 is H2O <br />Test End Time(TF): <br />09:12:00 <br />09:15:00 <br />Final Reading (RF): <br />30.00 in. H2O <br />29.00 in. H2O <br />Test Duration(TF—Tl): <br />1 min <br />1 min <br />Change in Reading (RF—RI) <br />0.00 in. H2O <br />-L00 in. H2O <br />Pass/Fail Threshold or Criteria:/- <br />+/-4.00 <br />+/-4.00 <br />Test Result: '' <br />Pass <br />Pass <br />Comments - (include information on repairs made prior to testing and recontniended follow-up forfailed tests) <br />�C <br />AL <br />NT <br />CERT RCATION OF TECUMCIA <br />I hereby certify that all the information contained in this repon <br />Technician's Signature: <br />'State laws and regulations do not currently require testing to be performed <br />W0: 2325495 <br />N RESPONSB3LE FOR CONDUCTING THIS TESTING <br />is true, accurate, and in full compliance with legal requirements. <br />Date: 1/21/2016 <br />by a qualified contractor. However, local requirements may be more stringent. <br />