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• • 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 Date of Testing: 10-22-09 <br /> Facility Address: 508 W.Charter Way, Stockton CA 95206 <br /> Facility Contact: Surinder Singh Saini Phone: 209-465-3440 <br /> Date Local Agency Was Notified of Testing: 10-01-09 <br /> Name of Local Agency Inspector('(present during testing): Ray Von Flue <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Reliable Petroleum Services Inc. <br /> Technician Conducting Test: Robert Barnhart <br /> Credentials: X CSLB Contractor X ICC Service Tech. ❑SWRCB Tank Tester ❑Other(Sped) <br /> License Number(s): 883706 5252540-UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: X Hydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used: Standard Tape Measure Equipment Resolution:— <br /> Identify Spill Bucket(By Tank Tl: 87 Fill 172: 91 Fill T3: Diesel Fill <br /> Number,Stored Product, etc. <br /> Bucket Installation Type: X Direct Bury X Direct Bury X Direct Bury ❑Direct Bury <br /> 0 Contained in Sump 0 Contained in Sump ❑Contained in Sump 0 Contained in Sum <br /> Bucket Diameter: 12" 12" 12" <br /> Bucket Depth: 13 '/a' 121/411 12 <br /> Wait time between applying <br /> vacuum/water and start of test: 2min. 2min. 2min. <br /> Test Start Time(T): 9:218.m 9:198.m 9:188.m <br /> Initial Reading(RO: 12'/." 11 '/." <br /> Test End Time(TF): 10:31a.m 10:29a.m 10:289.m <br /> Final Reading(RF): 12 '/." 10 Y." 11 /a 1 " <br /> Test Duration(TF—Tt): 1hr. 10min. lhr. 10 min. 1hr. 10min. <br /> Change in Reading(RF-Rj): 0 1 inch 0 <br /> Pass/Fail Threshold or <br /> Criteria: 1/16" 1/16" 1/16" <br /> Test Resut- X Pass 0 Fail 11 Pass X Fail X Pass 0 Fail ❑ Pass ❑Fail <br /> C011lMIlts—(include information on repairs made prior to testing, and recommended follow-!Eor failed tests) <br /> T2: 91 Fill SDill Bucket failed test Have already aQheduled inspections with Rav <br /> Von Flue for Bucket replacement <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 /> Tcchnicim's Signature: )' p — Date: 10-22-09 <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 />