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1 , <br /> 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 coRECEIVED <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 /> 2015 <br /> Facility Name:CHEVRON#99840 Date of Testing:l/ <br /> Facility Address:4344 E WATERLOO RD @ 99,STOCKTON,CA 95215 E� ! , ng eiTficha <br /> Facility Contact:MANAGER Phone:209-931-2186 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(!f present during testing): <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name:TANKNOLOGY INC. <br /> Technician Conducting Test:Gilbert Garcia <br /> Credentials): W' CSLB Contractor WO ICC Service Tech. r SWRCB Tank Tester r Other(Specify) <br /> License Number(s):743160 <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used By: W Hydrostatic r Vacuum Other <br /> Test Equipment Used:LAKE TEST Equipment Resolution:0.0625 in. <br /> Identify Spill Bucket(By Tank Spill Box#Tank T1 Spill Box#Tank T2 REG <br /> Number, Stored Product, etc.) SUPREME-Fill I -Direct- UNLEAD-Fill i -Direct- Spill Box# Spill Box# <br /> Grade level Grade level <br /> ro Direct Bury !o' Direct Bury r Direct Bury C Direct Bury <br /> Bucket Installation Type: r Contained in Sump r-, Contained in Sump C Contained in Sump f Contained in Sump <br /> Bucket Diameter: 12.00 12.00 <br /> Bucket Depth: 14.00 14.00 <br /> Wait time between applying 1 min 1 min min min <br /> vacuum/water and start of test <br /> Test Start Time(Tl): 10:05:00 10:05:00 <br /> Initial Reading(RI): 13.00 in. 12.50 in. <br /> Test End Time(TF): 11:05:00 11:05:00 <br /> Final Reading(RF): 13.00 in. 12.50 in. <br /> Test Duration(TF—TI): i hr 1 hr <br /> Change in Reading(RF—RI): 0.00 in. 0.00 in. <br /> Pass/Fail Threshold or Criteria: +/-0.00 +/-0.00 <br /> Test Results: <br />