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SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intended for use by contractors performing annual ill containment structures. The completed form and <br /> go testing <br /> o'USTsp <br /> provided to the fecffl�onrlbperator for submittal to the local regulatory agency. <br /> printouts from tests(if applicable),should be <br /> 1. FACILITY INFORMATION <br /> Facility Name: Chevron Date of Testing:1/19/12 <br /> Facility Address: 1103 S. Main St <br /> Manteca,CA 95337-5743 <br /> Facility Contact: Manager (209)825-0174 <br /> Date Local Agency Was Notified of Testing: 1/10f 12 <br /> Name of Local Agency Inspector (if present duting testing): <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name:Service Station Systems <br /> Technician Conducting Test; Randy Wilkerson <br /> -Credentials': 0 CSLB Contractor E] ICC Service Tech, [-]SWRCB Tank Tester C] Other(Specify) <br /> License Number(s): License;485184 ICC:5258560-UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used; QX Hydrostatic Q Vacuum El Other <br /> Test Equipment Used: Measuring Tape Equipment Resolulion:11/16 in. <br /> Identify Spill Bucket (By Tank I Fill Bucket 2 Fill Bucket 3 ; FM Bucket 4 <br /> Number,Stored Product,etc.) 01 Prem 02 Re 03 R22-U <br /> Bucket Installation Type: Direct Bury [S] Direct Bury QDirect Bury FI Direct Bury <br /> E].Contained in Sump E]Contained in Sump C]Contained in Sump Q Contained in Sump <br /> Bucket Diameter: 12.00 in. 12.00 in. 12.00 in. <br /> Bucket Depth: 14.00 in. 14.00 in. <br /> 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 ff�): 13,500 in, 13.250 in, 13.250 in. <br /> Test Duration(TF-T j: 1.00 hr. 1.00 hr, 1.00 hr. <br /> Change in Reading(RF -Rj 0.0000 in. 0.0000 in, 0.0000 in. <br /> Pass/Fail Threshold or Criteria: ZERO LOSS ZERO LOSS ZERO LOSS <br /> Test ReSidt.- Pass ❑Fall 1@ Pass E3 Fail 0 Pass 0 Fail <br /> Comments: Replaced 91 Fill 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,accurateand in full compliance with legal requirements. <br /> Technician's Signature "If_j <br /> Date: 1/19/12 <br /> State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements <br /> maybe more stringent. <br />