Laserfiche WebLink
P <br />0 <br />SWRCB, January 2006 <br />Spill Bucket Testing Report Form <br />This form is intended for use by contractors performing annual to Oing of UST spill containment structures. The complete <br />printouts from tests (ifapplicable), should be provided to the fac'lity owner/operator for submittal to the local regu/ato K W y Lj <br />1. <br />CHEVRON 21 <br />Facility Address: 1442A COLONY DR., RIPON, CA 95366 <br />Facility Contact: PATTY <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (iforesent during testim. <br />2. TF.STTNG <br />Date of Testing: 1/21/2016 <br />Phone: 209-599-0149 <br />ACTnR MFnPX4AT1l 1N <br />Company Name: TANKNOLOGY INC. <br />Technician Conducting Test: Jarrod Cooke <br />Credentialst: r CSLB Contractor r ICC Service Tech. SWRCB Tank Tester i" Other (Specify) <br />License Number(s): 8155550 <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used By: r Hydrostatic r Vacuum r 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 - FillI- Direct - <br />Grade level in containment <br />sump <br />T <br />C <br />Spill Box # Tank <br />ZAEGULARUNLEADED <br />ULAR-Fill I - Direct - <br />rade level in containment <br />sum <br />Spill Box # <br />Spill Box # <br />Bucket Installation Type: <br />l' Direct Bury <br />r Contained in Sump <br />!" Direct Bury <br />f Contained in Sump <br />C Direct Bury <br />r Contained in Sump <br />12.00 <br />12.50 <br />Direct Bury <br />Contained in Sump <br />12.00 <br />12.50 <br />Bucket Diameter: <br />Bucket Depth: <br />Wait time between applying <br />vacuum/water and start of testmin <br />min <br />5 min <br />5 min <br />Test Start Time (TI): <br />09:11:00 <br />30.00 in. H2O <br />09:12:00 <br />30.00 in. H2O <br />I mm <br />09:14:00 <br />30.00 in. H2O <br />09:15:00 <br />29.00 in. H2O <br />I mm <br />Initial Reading (RI): <br />Test End Time(Tg): <br />Final Reading (RF): <br />Test Duration(TF-TI): <br />Change in Reading (RF -RI) : <br />0.00 in. H2O <br />-1.00 in. H2O <br />Pass/Fail Threshold or Criteria: <br />+/- <br />+/-4.00 <br />+/-4.00 <br />Test Result: <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 I <br />I hereby certify that all the information contained in this report is <br />Technician's Signature: <br />t State laws and regulations do not currently require testing to be performed by <br />WO: 2325495 <br />tESPONSIBLE FOR CONDUCTING THIS TESTING <br />true, accurate, and in full compliance with legal requirements. <br />Date: 1/21/2016 <br />a qualified contractor. However, local requirements may be more stringent. <br />