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Spill Bucket Testing Report Form <br /> SWRCB,January 2006 <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(d applicable),should be provided to the facility owner/operator for submittal to the focal regulatory agency. <br /> 1.FACILITY INFORMATION <br /> Facility Name: Chevron Date of Testing:1/19/12 <br /> Facility Address: 1103 S. Main St Manteca, CA 95337-5743 <br /> Facility Contact: Manager (209)825-0174 <br /> Date Local Agency Was Notified of Testing: 1/10/12 <br /> Name of Local Agency Inspector (ffpresent during testing): <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name:Service Station Systems <br /> Technician Conducting Test: Randy Wilkerson <br /> Credentials: pX CSLB Contractor ®ICC Service Tech. ❑SWRCB Tank Tester E] Other(Specify) <br /> License Number(s): License:485184 ICC:5258560-UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ® Hydrostatic vacuum I] Other <br /> Test Equipment Used: Measuring Tape Equipment Resolution:1/16 in. <br /> Identify Spill Bucket (Sy Tank 1 Fill Bucket 2 Fill Bucket 3 FIII Bucket 4 <br /> Number,Stored Product,etc.) 01 Prem 02 Re u 03 Re u <br /> Bucket Installation Type: M Direct Bury ®Direct Bury Direct Bury ❑ Direct Bury <br /> Contained in Sump ❑Contained in Sump ❑Contained in Sump ❑Contained in Sump <br /> Bucket Diameter: 12.00 in. 12.00 in. 12.00 in. <br /> Bucket Depth: 14.00 in. 14.00 in. 14.00 in. <br /> Wait time between applying <br /> vacuum/water and start of test: 5 min' 5 min. 5 min. <br /> Test Start Time(Ti): 12:30pm 12:30pm 12:30pm <br /> Initial Reading(Ri ): 13.500 in. 13.250 in. 13.250 in. <br /> Test End Time(TF): 1:30pm 1:30pm 1:30pm <br /> Final Reading(R,-): 13,500 in. 13.250 in. 13.250 in. <br /> Test Duration(TF-T 1): 1,00 hr. 1.00 hr. 1.00 hr. <br /> Change in Reading(RF•Ri): 0.0000 in. 0.0000 in. 0.0000 in. <br /> Pass/Fail Threshold or Criteria: ZERO LOSS ZERO LOSS ZERO LOSS <br /> Test Result: ®Pass ❑Fail 0 Pass ❑Fail ❑X Pass ]Fail ®Pass ❑Fail <br /> Comments: Replaced 91 FIII Cap.Tested and passed. <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 Signature: kly" 1/1 <br /> Data: .9/12 <br /> t 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 />