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• 0 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: Charter Way Chevron I Date of Testing: 10-13-10 <br /> Facility Address: 508 Charter Way,Stockton,CA 95206 <br /> Facility Contact Rinku Phone: (209)165-3440 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(ffpresent during testing): Ray Von Flue <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Reliable Petroleum Services Inc. <br /> Technician Conducting Test: Guadalupe Sanchez <br /> Credentials: x CSLB Contractor x ICC Service Tech ❑SWRCB Tank Tester ❑Other(Specify) <br /> License Number(s): 883706 5250451-UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: xHydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used: Standard Tape Measure Equipment Resolution: <br /> Identify Spill Bucket(By Tank I Tl:87 Fill 2 T2:87 Fill 3 73: 91Diesel 4 <br /> )Vumber,Stored Product, etG fill <br /> Bucket Installation Type: x Direct Bury x Direct Bury x Direct Bury xDirect Bury <br /> U Contained in Sump 0 Contained in Sump ❑Contained in Sump 11 Contained in Sum <br /> Bucket Diameter. 12" 12" 12" <br /> Bucket Depth: 131/4" 131/4" 1212" <br /> Wait time between applying I minute I minute 1 minute <br /> vacuum/water and start of test: <br /> Test Start T®e(Ti): 9:02 a.m. 9:01 am 9:00 a-m. <br /> Initial Reading(Ri): 12''/4" 12 Y4" 12" <br /> Test End Time(TF): 10:00am_ 10:01a m. 10:02a m. <br /> Final Reading(RF): 12'b" 12'/4" 12" <br /> Test Duration(TF—T�: 1 hr ibr 1 hr <br /> Change in Reading(RF-Rj: 0 0 0 <br /> Pass/Fail Threshold or 1116" 1116" 1/16" <br /> Criteria: <br /> Test Result: a Pass ❑Fail a Pass ❑Fai1 a Pass ❑Fail Pass ❑Fail <br /> Comments—(include information on repairs made prior to testing and recommended follow-up for failed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that aU the information contained in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: —� - ' / ' Date 10-13-2010 <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 />