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0 0 SWRCB, January 2006 <br />9. Spill Bucket Testing Report Form <br />This)orm 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 210997 (N-4693) <br />DateofTesting: 02/07/2011 <br />Facility Address: 1442A COLONY DR. , RIPON, CA, 95366 <br />Facility Contact: PATTY <br />Phone: (2 0 9) 599-0149 <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (if present during testing): Muni <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: TANKNOLOGY , INC. <br />Technician Conducting Test: STEVEN WILLEMS <br />Credentials l: <br />❑X <br />CSLB Contractor ❑x ICC Service Tech. El SWRCB Tank Tester <br />FV-1 <br />Other (Specify) icc <br />License Number: 8016974 <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: ❑X Hydrostatic ❑ Vacuum E Other <br />Test Equipment Used: tape measure <br />Equipment Resolution: 0 loss <br />Identify Spill Bucket(By Tank <br />]Number, Stored Product, etc.) <br />1 1 UNL FILL <br />2 2 UNI. FILL <br />3 <br />4 <br />Bucket Installation Type: <br />Direct Bury <br />X❑ Contained in Sump <br />❑ Direct Bury <br />® Contained in Sump <br />Direct Bury <br />❑ Contained in Sump <br />❑ Direct Bury <br />Q Contained in Sump <br />Bucket Diameter: <br />1211 <br />12" <br />Bucket Depth: <br />12.511 <br />11.7511 <br />Wait time between applying <br />vacuum/water and starting test: <br />5 mins <br />5 mins <br />Test Start Time (T <br />9:56 <br />9.56 <br />Initial Reading (RE ): <br />12.5" <br />11.75" <br />Test End Time (TF ): <br />10:56 <br />10:56 <br />Final Reading (RF ): <br />12.511 <br />11.7511 <br />Test Duration: <br />1 hour <br />1 hour <br />Change in Reading (R F - RI ): <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />0 loss <br />0 loss <br />Test Result: <br />0 Pass ❑ Fail <br />0 Pass <br />❑ Fail <br />❑ Pass ❑ Fail <br />El <br />Pass <br />❑ Fail <br />Comments - (include information on repairs made prior to testing, and recommended follow-upforfailed 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: , . Date: <br />02/07/.2011 <br />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 />