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<br /> Spill Bucket Testing Report Form RECEIVED
<br /> This form is intended for use by contractors performing annual testing of UST spill containment structures. The completed for d ����
<br /> printouts from tests(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory a
<br /> 1.FACILITY INFORMATION ENVIRONMENTAL
<br /> Facility Name:CHEVRON#208117 Date of Testing:2/10/20 !TP n�:70A
<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:Gilbert Garcia
<br /> Credentials]: P7 CSLB Contractor r— ICC Service Tech. M SWRCB Tank Tester r-7-1 Other(Specify)
<br /> License Number(s):743160
<br /> 3.SPILL BUCKET TESTING INFORMATION
<br /> Test Method Used By: M Hydrostatic FF, Vacuum MA Other
<br /> Test Equipment Used:VACUUM TEST Equipment Resolution:0.1 gph
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<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 /> Direct Bury C Direct Bury Direct Bury Direct Bury
<br /> Bucket Installation Type: Contained in Sump G, Contained in Sump r Contained in Sump Contained in Sump
<br /> Bucket Diameter: 12.00 12.00
<br /> Bucket Depth: 12.50 12.50
<br /> Wait time between applying
<br /> vacuum/water and start of test 1 min 1 min min min
<br /> Test Start Time(Tl): 09:08:00 09:04:00
<br /> Initial Reading(Rl): 30.00 in.H2O 30.00 in.H2O
<br /> Test End Time(TF): 09:09:00 09:05:00
<br /> Final Reading(RF): 30.00 in.H2O 30.00 in.H2O
<br /> Test Duration(TF—T]): 1 min 1 min
<br /> Change in Reading(RF—R]): 0.00 in.H2O 0.00 in.H2O
<br /> Pass/Fail Threshold or Criteria: +/-4.00 +/-4.00 +/-
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<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: s — Date: 2/10/2016
<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:2326364
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