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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 ownerloperatorfor submittal to the local regulatory agency. <br />1. FACILITY INFORMATION,, <br />Facility Name: Wilson Way Chevron I Date of Testing: 02/15/2011 <br />Facility Address: 437 N. Wilson Way —Phone: 209-942-2344 <br />Facility Contact: Aman Mehroke <br />Date Local Agency Was Notified of Testing: 6-a-ge- /I <br />Name of Local Agency Inspector (if present during testing): Jeff Wong <br />3. SPELL BUCRET TESTING INFORMATION <br />TestEquipment T Test MethodUsed: xHydrostatic 0 Vacuum 0 Other <br />e" Me" <br />Test Used: Standard Tape Measure Equipment Resolution: <br />Identify Spill %Hcket (By Tank <br />Number, Stored Product, �eta <br />Bucket Installation Type: <br />I TI: 87 Fill <br />Direct Bury <br />x Contained in Sump <br />2 T2: 91 Fill <br />Direct Bury <br />x Contained in Sum p <br />3 T3: <br />Direct Bury <br />i-1 Contained in Sump <br />4 T4: <br />Direct Bury <br />01 Contained in Sump <br />Bucket Diameter: <br />12" <br />12" <br />Bucket Depth: <br />173/4" <br />16" <br />Wait time between applying <br />vacuum/water and start of test: <br />I minute <br />I minute <br />Test Start Time (Ti): <br />10:25 am. <br />10:32 am. <br />Initial Reading (Rt): <br />143/4" <br />1311 <br />Test End Time (TF): <br />11:25 am. <br />11:32 am. <br />Final Reading (RF): <br />143/4" <br />13" <br />Test Duration (TF - Tj): <br />I hr <br />1 h <br />Change in Reading (RF- Rj): <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />1/16" <br />1/16" <br />Test Result: <br />x Pan 0 Fail <br />x Pass 0 Fail <br />Pan 0 Fail <br />Pass 0 Fail <br />Comments — (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 In full compliance with legal requirements. <br />Technician's Date 02(1512011 <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 />