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.7 <br />.7 <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 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: Wilson Way Chevron Date of Testing: 02/15/2011 <br />Facility Address: 437 N. Wilson Way <br />Facility Contact: Aman Mehroke Phone: 209-942-2344 <br />Date Local Agency Was Notified of Testing: - 't - // <br />Name of Local Agency Inspector (tfpresent during testing): Jeff Wong <br />liz 0 full I <br />3_ SPH.i. RTT('K ..T TFCTMr_ iNMUM®TMAT <br />Test Method Used: <br />xHydrostatic <br />0 Vacuum <br />❑ Other <br />Test EquipnWnt Used: Standard Tape Measure <br />Identify Spill Jacket (By Tank 1 Ti: 87 Fill <br />Number, Stored Product, etc. <br />2 T2: 91 Fill <br />Equipment Resolution: <br />3 T3: <br />4 T4: <br />Bucket Installation Type: <br />Direct Bury <br />x Contained in Sump <br />Direct Bury <br />x Contained in Sump <br />Direct Bury <br />❑ Contained in Sump <br />Direct Bury <br />❑ Contained in Sum <br />Bucket Diameter: <br />12" <br />12" <br />Bucket Depth: <br />17 %" <br />16" <br />Wait time between applying <br />vacuum/water and start of test: <br />1 minute <br />1 minute <br />Test Start Time (TI): <br />10:25 am. <br />10:32 a.m. <br />Initial Reading (RI): <br />143/4" <br />13" <br />Test End Time (TF): <br />11:25 a.m. <br />11:32 a.m. <br />Final Reading (RF): <br />14 3/4" <br />13" <br />Test Duration (TF - TI): <br />1 hr <br />hr <br />Change in Reading (RF - RI): <br />0 <br />—I <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />1/16" <br />1/16" <br />Test Result: <br />x Pass ❑ Fail <br />x Pass ❑ Fail <br />Pass ❑ Fail <br />Pass ❑ Fail <br />uommenls —(include information on repairs made prior to testing, and recommended follow-up for failed tests) <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 infill compliance with legal requirements. <br />Technician's Sign,C, <br />r� v Date 02/15/2011 <br />' 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 />