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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 e <br /> nc <br /> E- E , <br /> 1.FACILITY INFORMATION <br /> Facility Name:CHEVRON 4208117 1 Date of Testing:2/23/2015 IVI <br /> Facility Address:755 S.TRACY BLVD,TRACY,CA 95376 i <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):STACY <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name:TANKNOLOGY INC. <br /> Technician Conducting Test:Jarrod Cooke <br /> Credentials): r— CSLB Contractor rICC Service Tech. SWRCB Tank Tester r— Other(Specify) <br /> License Number(s):5311523 <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used By: Hydrostatic 17 Vacuum Other <br /> Test Equipment Used:VACUUM TEST Equipment Resolution:0.1 gph <br /> Spill Box#Tank T 2 Spill Box#Tank T 1 Spill Box#Tank T 1 <br /> Identify Spill Bucket(By Tank REGULAR-Fill I -Direct- PREMIUM-Fill I -Direct- PREMIUM-Fill 1-Direct- Spill Box# <br /> Number, Stored Product, etc.) Grade level in containment Grade level in containment Grade level in containment <br /> sump sump sump <br /> C" Direct Bury r Direct Bury r Direct Bury r Direct Bury <br /> Bucket Installation Type: r Contained in Sump ro Contained in Sump r Contained in Sump r Contained in Sump <br /> Bucket Diameter: 12.00 12.00 12.00 <br /> Bucket Depth: 12.25 12.25 12.25 <br /> Wait time between applying <br /> 5 min 5 min 5 min min <br /> vacuum/water and start of test <br /> Test Start Time(TI): 10:15:00 10:34:00 12:40:00 <br /> Initial Reading(RI): 30.00 in.H2O 12.25 in. 30.00 in.H2O <br /> Test End Time(TF): 10:16:00 11:34:00 12:41:00 <br /> Final Reading(RF): 28.00 in.H2O 11.00 in. 30.00 in.H2O <br /> Test Duration(TF--TI): 1 min 1 hr 1 min <br /> Change in Reading(RF—Rt): -2.00 in.H2O -1.25 in. 0.00 in.H2O <br /> Pass/Fail Threshold or Criteria: +/-4.00 +/-0.00 +/-4.0017717 <br /> Test Result; 1' ss : Flail lass <br /> Comments-(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> SUP SB FAILED FIRST TEST.BUCKET WAS CLEANED AND SHUT OFF O-RING WAS REPLACED.AND BUCKET PASSED. <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: 2/23/2015 <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 /> WO:2321578 <br />