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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#208117 Date of Testing:2/8/2017 <br /> Facility Address:755 S.TRACY BLVD,TRACY,CA 95376 <br /> Facility Contact:MGR-MARIA Phone:209-830-0370 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name:TANKNOLOGY INC. <br /> Technician Conducting Test:Darren Sciume <br /> Credentials): P CSLB Contractor ry-1 ICC Service Tech. r— SWRCB Tank Tester r— Other(Spec <br /> License Number(s):743160 <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used By: Hydrostatic Vacuum Other <br /> Test Equipment Used:LAKE TEST Equipment Resolution:0.0625 in. <br /> Spill Box#Tank T 1 Spill Box#Tank T 2 <br /> Identify Spill Bucket(By Tank PREMIUM-Fill 1 -Direct- REGULAR-Fill 1-Direct- Spill Box# Spill Box# <br /> Number, Stored Product, etc.) Grade level in containment Grade level in containment <br /> sump sump <br /> C` Direct Bury r Direct Bury r Direct Bury r Direct Bury <br /> Bucket Installation Type: ro Contained in Sump ro Contained in Sump C Contained in Sump r Contained in Sump <br /> Bucket Diameter: 11.00 11.00 <br /> Bucket Depth: 12.00 12.00 <br /> Wait time between applying <br /> 15 min IS min min min <br /> vacuum/water and start of test <br /> Test Start Time(Tl): 11:00:00 11:30:00 <br /> Initial Reading(Rl): 10.50 in. 10.50 in. <br /> Test End Time(TF): 12:00:00 12:30:00 <br /> Final Reading(RF): 10.50 in. 10.50 in. <br /> Test Duration(TF-TI): 1 hr 1 hr <br /> Change in Reading(RF-RI): 0.00 in. 0.00 in. <br /> Pass/Fail Threshold or Criteria: +/-0.0250 +/-0.0250 <br /> Test Result: Pass Pass'' <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 Signature: Date: 2/8/2017 <br /> 'State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements may be more stringent. <br /> W O:2329827 <br />