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Nov 23 09 10:54a Reliable Petroleum: 209-845-8953 p.6 <br /> • <br /> SWRC$,January 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intended for use by contractors perfonning annual testing of UST spill conlainment structures. The completed form and <br /> printoutsfrom tests(if applicable), should be provided to the facility owner,%perata forsubmittal to the local regulatory agency- <br /> 1. <br /> gency1. FACILITY INFORMATION <br /> FFacffitv <br /> ame: CHARTER WAY CHEVRON Dare of Testis <br /> ddress: 508 W. Charter Way, Stockton CA 95206 g' 10-22-09 <br /> ntact: Surinder Singh SainiPhone: 209-465-3440 <br /> Agency Was Notified of resting: 10-01-09 <br /> Name of Local Agency Inspector(lfpresent 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, n S WRCB Tark Tester ❑Other(Sped) <br /> LicenseNumber(s): 883706 5252540.UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: X Hydrostatic ❑Vacuum ❑Othct. <br /> Test Equipment Used: Standard Tape Measure <br /> Equipment Resolution:— <br /> Identify Spill Bucket(By Tank Tl:87 Fill T2: 91 Fill <br /> Number,Stored Product, etc.) T3: Diesel Fill <br /> Bucket Installation Type: X Direct Bury X Direct Bury X Direct Bury <br /> C Contained ' Sum ❑Direct Bury <br /> Bucket Diameter. G Contained in S G Contained in Sum ❑Contained in Sum <br /> 12 16" 12„ <br /> Bucket Depth: <br /> W. <br /> Wait time between applying 12 Y2" <br /> vacuum/water and start of test. 2mi°• 2min. 2min <br /> Test Start Time(Tl): <br /> Initial Reading W: 9:21a.m <br /> 12 /. <br /> 9:193.m 9:18a.m <br /> , „ 11 <br /> Test End Time(Tr): 10:313.m <br /> 10:29a.m 10:28a.m <br /> Final Reading(RF): 121/11 10 Y." <br /> Test Duration T T I I <br /> ( r— il� lhr. lOmin. ]hr. 10 min. <br /> Change in Read' 1hr. Ionun. <br /> °18(Rr-Rt). 0 1 inch <br /> Pass/Fail Threshold or 0 <br /> Criteria: 1/16" 1116" 1/16" <br /> Test Result: X Pass ❑ Fait <br /> ❑ Pass X Fail X Pass G Fail ❑ Pass ❑Faii <br /> Comments—(include information on repairs made riot la testis and recommendedfoliow-u orfailed tests) <br /> T2: 91 Fill SHill Bucket failed test Have already scheduled in <br /> Yon F1ii f rBucket rei2faceinnent. snectl W with Ray <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> Flrereby ceR that all the information contained in this report Is true,accurate,and in full conrpllance with legal requirements <br /> Tccbnicia,Ys Signature:_ �t -h-- <br /> 11 l.t 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 />