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Spill Bucket Testing Report Form J ! 201 <br /> This form is intended for use by contractors performing annual testing of UST spill containment structures. The complete'form and <br /> printouts from tests (if applicable), should be provided to the facility owner/operator.for submittal to the local regulatoryagencv. <br /> 1. FACILITY INFORMATION <br /> Facility Name: CHEVRON Date of Testing: 6/19/2015 <br /> Facility Address: 444 MOSSDALE City: LATHRUP <br /> Facility Contact: PAL Phone: <br /> Date Local Agency Was Notified of Testing: Wednesday,June 10,2015 <br /> Name of Local Agency Inspector(if'present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: BZ Service Station Maintenance <br /> Technician Conducting Test: ALEXANDER TATE <br /> Credentials': E CSLB Contractor ICC Service Tech. ❑ SWRCB Tank Tester ❑Other(Specify) <br /> License Number(s): 433159 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ® Hydrostatic ❑ Vacuum ❑Other <br /> Test Equipment Used: TAPE MEASURE Equipment Resolution: 1/16" <br /> Identify Spill Bucket (By, Tank 1 87 2 91 3 DSL 4 <br /> Number, Stored Product, etc.) <br /> Bucket Installation Type: ® Direct Bury ® Direct Bury ® Direct Bury ❑ Direct Bury <br /> ❑Contained in Sump ❑ Contained in Sump ❑ Contained in Sum ❑ Contained in Sum <br /> Bucket Diameter: 11" 11" 11" <br /> Bucket Depth: 10.5" 10.75" 12.5" <br /> Wait time between applying 5 MIN 5 MIN 5 MIN <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 10:13 10:13 12:48 <br /> Initial Reading(R,): 10.25" 10.5" 11" <br /> Test End Time(TF): 11:13 11:13 1:48 <br /> Final Reading(RF): 10.25" 10.5" 11" <br /> Test Duration(TF—Tt): 1 HR IHR IHR <br /> Change in Reading(RF—R,): 0 0 0 <br /> Pass/Fail Threshold or 0 p 0 <br /> Criteria: <br /> Test Result: ® Pass ❑Fail ® Pass ❑ Fail ® Pass El Fail El Pass- El Fail <br /> Comments— (include information on repairs made prior to testing, and recommended follow-up,for failed tes(s) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the information contained in this repo 's true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: r.. - Date: 6/19/2015 <br /> State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more <br /> stringent. <br /> Monitoring Certification Test Report <br /> 4 of 4 <br />