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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 201761 Date of Testing: 1/2/2020 <br /> Facility Address: 1103 S.MAIN ST.PERMIT NUMB.N-3315,MANTECA,CA 95337 <br /> Facility Contact:MGR-MARIE Phone:209-825-0174 <br /> Date Local Agency Was Notified of Testing: 1/2/2020 <br /> Name of Local Agency Inspector(if present during testing):Environmental <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name:TANKNOLOGY INC. <br /> Technician Conducting Test: Brent Bowen <br /> Credentials I: r CSLB Contractor If ICC Service Tech. M SWRCB Tank Tester r Other(Specify) <br /> License Number(s):74360 <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used By: r Hydrostatic r Vacuum r Other <br /> Test Equipment Used:LAKE TEST Equipment Resolution:0.0625 in. <br /> Spill Box#Tank T 1 Spill Box#Tank T2 Regular Spill Box#Tank T3 Regular <br /> Identify Spill Bucket(By Tank Supreme SUPREME-Fill 1 2 REGULAR-Fill 1-Direct I REGULAR-Fill I-Direct Spill Box# <br /> Number,Stored Product, etc.) -Direct-Grade level in -Grade level in -Grade level in <br /> containment sump containment sump containment sump <br /> C' Direct Bury r Direct Bury r Direct Bury r Direct Bury <br /> Bucket Installation Type: r Contained in Sump C• Contained in Sump �*` Contained in Sump r Contained in Sump <br /> Bucket Diameter: 12.00 12.00 12.00 <br /> Bucket Depth: 14.00 14.00 14.00 <br /> Wait time between applying <br /> 14 min 15 min IS min min <br /> vacuum/water and start of test <br /> Test Start Time(Tl): 09:00:00 09:00:00 09:00:00 <br /> Initial Reading(Rl): 14.00 in. 14.00 in. 14.00 in. <br /> Test End Time(TF): 10:00:00 10:00:00 10:00:00 <br /> Final Reading(RF): 14.00 in. 14.00 in. 14.00 in. <br /> Test Duration(TF—Tl): 1 hr I hr 1 hr <br /> Change in Reading(RF—Rl): 0.00 in. 0.00 in. 0.00 in. <br /> Pass/Fail Threshold or Criteria: +/-0.0025 +/-0.0025 +/-0.0025 +/- <br /> Test Result: Pass 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: 1/2/2020 <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:2343354 <br />