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Nov 23 09 10:54a Reliable PetroleumAA 209-845-8953 p.7 <br /> Spill Bucket Testing Report Form SWRCB,January 2006 <br /> This form is intendedfor use by contractors performing annual testing of UST spill containment structures. The completed form and <br /> printoutsfrom tests ftfapplicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> EName <br /> Nae: CHARTER WAY CHEVRON Date of Testing: 10-22-09 <br /> ress: 508 W.Charter Way, Stockton CA 95206 <br /> tact: Surinder Singh Saint <br /> Phone: 209-465-3440 <br /> gency Was Notified of Testing: 10-23-09 <br /> cal Agency Inspector(fpresent 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(Spec fy) <br /> License Number(s): 883706 5252540-UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: X Hydrostatic G Vacuum <br /> Test Equipment Used: Standard Tape Measure ❑Other <br /> 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 Bur, D Direct Bury ❑Bisect Bury <br /> C Contained in Sump C Contained in Su]nP L Contained in Sum =Contained in Sum <br /> Bucket Diameter: 12" <br /> Bucket Depth: 133181, <br /> Wait time between applying <br /> vacuum/water and start of test: ]min, <br /> Test Start Time (T,): 9:203.m <br /> Initial Reading(Ri): 121/81, <br /> Test End Time (TF): 10:20a.m <br /> Final Reading(RF): 121181, <br /> Test Duration (TF—Tr): 1 hr. <br /> Change in Reading(RF-1�): 0 <br /> Pass/Fail Threshold or <br /> Criteria: 1116" <br /> Test Result: X Pass ❑Fail <br /> D Pass ❑Fail <br /> Comments—(include information on repairs made prior to t0 Pass ❑Fait El Pass 11 Fail <br /> estin , and recommendedfollow-u for failed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> !bereby certify"bat all the information contained in tills report is true, accurate,and in full compliance will:legal requirements. <br /> Technician's Signature: <br /> Date: 10-22-09 <br /> State taws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements <br /> may be more stringent. <br />