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07/23/2013 09:36 (209) 465-4988 MaryAnn Henderson Page 5/5 <br />0 <br />SWRCB, January 2006 <br />This form is Intendedfor use by contractors performing annual testing of USPspitt containment structures. Yate completed form and <br />printouts from tests (if applicable), should be provided to the facility ownerloperatorfor submittal to the local regulatory agency. <br />Facility Name: CHEVRON I Date of Testing: 6-20-13 <br />Facility Address: 3 304 WEST HAMMER LN STOCKTON,CA <br />Facility Contact: I Phone: <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector r1fpresent during testing): INSP ONS / NO INSP ON SITE <br />2. TESTJfG CM"t . it OKI, FLIR'- WT " 001 <br />Company Name: Service Station Testing, Inc. <br />Technician Conducting Test: Charles Ferrucci <br />Credentials' : 0 CSLB Contractor 0 ICC Service Tech. 0 SWRCB Tank Tester 0 Other (S ecify) <br />License Number(s): 5323096 -UT <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: 0 Hydrostatic 0 Vacuum 0 Other <br />Test Equipment Used: Water, Tape Measure, Stop Watch Equipment Resolution: 1/16" <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />I REG FILL <br />2 DSL FILL <br />3 PREM Fill <br />4 <br />Bucket Installation Type: <br />a Direct Bury <br />11 Contained in Sump <br />Z Direct Bury <br />0 Contained in Sump <br />R Direct Bm-y <br />0 Contained in Sump <br />Q Direct Bury <br />0 Contained in Sump <br />Bucket Diameter: <br />12 <br />12 <br />12 <br />Bucket Depth: <br />12 <br />14 <br />12 <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (T): <br />ow <br />0840 <br />0840 <br />Initial Reading W: <br />11.25 <br />13 <br />10.75 <br />Test End Time (Ty): <br />0940 <br />0940 <br />0940 <br />Final Reading (RF): <br />11.25 <br />13 <br />10.75 <br />Test Duration (TF - T): <br />I hr <br />I hr <br />I hr <br />Change in Reading (RF -R): <br />0 <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />0 <br />0 <br />Test Result: <br />Z- Pass 0 Fail <br />E Pass 0 Fail <br />E Pass 0 Fag <br />0 Pass 0 Fail <br />Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />REPLACM FILL CAP -O-PW QN REGULAR SPILL BUCKET TO GET <br />PASSING RESULT <br />CERTIFICATION 9,F TEC31NI RESPONSIBLE FOR CONDUCTING THIS TESTING <br />I kereby certify that all thewrnzdwnc_o ed In this report& fte, accurate, and infullcomplkmce Ifth al requirements. <br />�W7! ;=n <br />I (ell <br />Technician's Si Date: <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 />