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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 completed form and <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 /> Facility Name:CHEVRON 201761 Date of Testing: 1/4/2018 <br /> Facility Address: 1103 S.MAIN ST.PERMIT NUMB.N-3315,MANTECA,CA 95337 <br /> Facility Contact:MGR-MARIE Phone:209-825-0174 <br /> Date Local Agency Was Notified of Testing: 12/12/2017 <br /> Name of Local Agency Inspector(if present during testing):betty ho <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name:TANKNOLOGY INC. .1 <br /> Technician Conducting Test:Jarrod Cooke <br /> Credentials): r— CSLB Contractor R ICC Service Tech. r' SWRCB Tank Tester r— Other(Specify) i <br /> License Number(s):8155550 <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used By: Hydrostatic P: Vacuum Other <br /> Test Equipment Used:VACUUM TEST Equipment Resolution:0.1 gph <br /> 777777777 <br /> Spill Box#Tank T 1 Spill Box#Tank T2 Spill Box#Tank T3 <br /> Identify Spill Bucket(By Tank Supreme SUPREME-Fill I Regular 2 REGULAR-Fill 1 Regular 1 REGULAR-Fill l Spill Box# <br /> Number, Stored Product, etc.) -Direct-Grade level in -Direct-Grade level in -Direct-Grade level in <br /> containment sump containment sump containment sump <br /> r~ Direct Bury r Direct Bury r" Direct Bury r' Direct Bury <br /> Bucket Installation Type: ro Contained in Sump r* Contained in Sump ro Contained in Sump r Contained in Sump <br /> Bucket Diameter: 12.00 12.00 12.00 <br /> Bucket Depth: 12.50 12.50 12.50 <br /> Wait time between applying <br /> 5 min 5 min 5 min min <br /> vacuum/water and start of test <br /> Test Start Time(Tl): 09:09:00 09:12:00 09:16:00 <br /> Initial Reading(Rl): 30.00 in.H2O 30.00 in.H2O 30.00 in.H2O <br /> Test End Time(TF): 09:10:00 09:13:00 09:17:00 <br /> Final Reading(RF): 30.00 in.H2O 26.00 in.H2O 26.00 in.H2O <br /> Test Duration(TF—Tl): 1 min 1 min 1 min <br /> Change in Reading(RF—Rl): 0.00 in.H2O -4.00 in.H2O -4.00 in.H2O <br /> Pass/Fail Threshold or Criteria: +/-4.00 +/-4.00 +/-4.00 +/- <br /> Test Resull Pass 1'as _ ?as <br /> Comments-(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING TIIIS 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: C/�� Date: 1/4/2018 <br /> 1 State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements may be more stringent. <br /> WO:2334167 <br />