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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: Chevron I Date of Testing: 110/13/2011 <br /> Facility Address: 508 Charter Way,Stockton,Ca.95206 <br /> Facility Contact: Rinku I Phone: (209)465-3440 <br /> Date Local Agency Was Notified of Testing: 10-04-11 <br /> Name of Local Agency Inspector(if present during testing): Stacy Rivera <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. 0 SWRCB Tank Tester 0 Other(Spec) <br /> License Number(s): 883706 5250451 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: xHydrostatic 0 Vacuum 0 Other <br /> Test Equipment Used: Standard Tape Measure Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1 Tl: 87 Fill 2 T2: 91 Fill 3 T3: Diesel Fill 4 T4: <br /> Number, Stored Product, etc. <br /> Bucket Installation Type: x Direct Bury x Direct Bury x Direct Bury Direct Bury <br /> Contained in Sump Contained in Sump Contained in Sump Contained in Sum <br /> Bucket Diameter: 12" 12" 12" <br /> Bucket Depth: 13" 131/2" 123/4" <br /> Wait time between applying 1 minute 1 minute 1 minute <br /> vacuum/water and start of test: <br /> Test Start Time(TO: 9:25 a.m. 9:25 a.m. 9:25 a.m. <br /> Initial Reading(Rj): 12" 12 3/8" 11 Y2" <br /> Test End Time(Tr): 10:25 a.m. 10:25 a.m. 10:25 a.m. <br /> Final Reading(RF): 12" 12 3/8" 111/21, <br /> Test Duration(TF—TO: 1 hr 1 hr 1 hr <br /> Change in Reading(RF-Rj): 0 0 0 <br /> Pass/Fail Threshold or 1/16" 1/16" 1/16" <br /> Criteria: <br /> Test Result: x Pass 0 Fail x Pass 0 Fail x Pass 0 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 all the information contained in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signatur!. Date 10/13/2011 <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 />