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JUN 2 7 2016 <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 <br /> form and printouts from tests(if applicable), should be provided to the facility ownerloperatorfor submittal to the local <br /> regulatory agency. <br /> 1.FACILITY INFORMATION <br /> Facility Name: CHEVRON Date of Testing:6/20/2016 <br /> Facility Address: 444 MOSSDALE City: L THROP <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: BF—Service Station Maintenance <br /> Technician Conducting Test: DAVID ROUSE <br /> Credentials': 10 CSLB Contractor ICC Service Tech. [I'SWRCB Tank Tester —Other(Specify) <br /> License Number(s): 433159 <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: Hydrostatic VacuumOther <br /> Test Equipment Used: I Equipment Resolution: <br /> 1 0112211111 - MMUZZ110= EMEREME11111= <br /> Identify Spill Bucket(By Tank 1 DSL 2 3 4 <br /> Number, Stored Product, e <br /> Bucket Installation Type: O'Direct�Bury Direct�Bury Direct Bury Lj Direct Bury <br /> El Contained in Sump El Contained in Sump El Contained in Sump ❑Contained in Sum <br /> Bucket Diameter: lift <br /> Bucket Depth: 1411 <br /> Wait time between applying <br /> vacuum/water and start of test. 5 MIN <br /> Test Start Time(Ti): 10:18 <br /> Initial Reading(111): 1311 <br /> Test End Time(TF): 11:18 <br /> Final Reading(RF): 13" <br /> Test Duration(TF—Ts): —1 HR <br /> Change in Reading(RF—R1): 0 <br /> Pass/Fail Threshold or <br /> Criteria: 0 <br /> F <br /> Test!C'SUIV 'rr Pa", <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up for <br /> 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 <br /> requirements. <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 /> Secondary Containment Test Results 3 of 3 <br />