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• SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intended foruse by contractors performing annual testing of UST spill containment structures. The completed form and <br /> printouts from tests(tf 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: 10-22-09 <br /> Facility Address: 508 W.Charter Way, Stockton CA 95206 <br /> Facility Contact: Surinder Singh Saini I Phone: 209465-3440 <br /> Date Local Agency Was Notified of Testing: 10-23-09 <br /> Name of Local Agency Inspector(rfpresent 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(Specify) <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 T2: 91 Fill Bucket <br /> Number,Stored Product, etc. <br /> Bucket Installation Type: X Direct Bury ❑Direct Bury ❑Direct Bury ❑Direct B <br /> ury <br /> ❑Contained in Sum ❑Contained in Sum ❑Contained in Sum D Contained in Sum <br /> Bucket Diameter: 12" <br /> Bucket Depth: 13 3/8" <br /> e betw <br /> Wait timeen applying <br /> vacuum/water and start of test: 1 min. <br /> Test Start Time(T,): 9:20a.m <br /> Initial Reading(Rt): 121/81, <br /> Test End Time(TF): 10:20am <br /> Final Reading(RF): 12 1/8" <br /> Test Duration(TF—TO: Mr. <br /> Change in Reading(RF-Rj): 0 <br /> Pass/Fail Threshold or <br /> Criteria: 1/16" <br /> Test Result: X Pass ❑Fail ❑ Pass D Fail <br /> ❑ Pass 11 Fail 11 Pass ❑Fail <br /> Comments—(include information on repairs made Prior to testing, and recommended follow-up or failed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby cerdfy that all the information contained in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: (TOAkch )1 1n � A <br /> 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 />