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SWRCB, January 2006 <br /> Spill Bucket Testing Report Form <br /> This fora: is intended for use by contractors performing annual testing of UST spill containment structures. The completed form and <br /> printouts frown tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1 . FACILITY INFORMATION <br /> Facility Narne : Chevron 372736 Date of Testing : 2/ 12/2020 <br /> Facility Address : 9484 West Lane , Stockton, CA_ 95210 <br /> Facility Contact: Diane Province Phone: 2094749825 <br /> Date Local Agency Was Notified of Testing: 2/5/2020 <br /> Im <br /> Name of Local Agency Inspector (if present during testing): PAUL <br /> 2 . TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY INC. Ir <br /> Technician Conducting Test: Jesus Saldivar <br /> Credentials ] : f CSLB Contractor r ICC Service Tech . r� SWRCB Tank Tester Other (Specify) <br /> License Number(s) : <br /> 3 . SPILL BUCKET TESTING INFORMATION <br /> Test Method Used By : Hydrostatic W Vacuum Other <br /> Test Equipment Used: Equipment Resolution : <br /> Spill Box # Tank T2 :Regular Spill Box # Tank Tl : PREM. Spill Box # Tank T3 : diesel <br /> Identify Spill Bucket (By Tank REGULAR - Fill 1 - Direct - PREMIUM - Fill 1 - Direct - Diesel - Fill 1 - Direct - Spill Box # <br /> Number, Stored Product, etc.) Below Grade in Below Grade in Below Grade in <br /> containment sump containment sump containment sump <br /> r Direct Bury t Direct Bury r Direct Bury r� Direct Bury <br /> Bucket Installation Type : r+ Contained in Sump r+ Contained in Sump t: Contained in Sump r Contained in Sump <br /> Bucket Diameter: 12.00 12.00 12.00 <br /> Bucket Depth : 16.50 16.00 16.00 <br /> Wait time between applying 1 min 1 min I min min <br /> vacuum/water and start of test <br /> Test Start Time (TI ): 09:00:00 09:02:00 09:04:00 <br /> Initial Reading (RI): 30.00 in. H2O 30.00 in. H2O 30.00 in. H2O <br /> Test End Time(TF): 09:01 :00 09:03 :00 09:05 :00 <br /> Final Reading (RF): 30.00 in. H2O 30.00 in. H2O 30.00 in. H2O <br /> Test Duration(TF—TI): I min 1 min 1 min <br /> Change in Reading (RF—RI) : 0.00 in. H2O 0.00 in. H2O 0.00 in. H2O <br /> Pass/Fail Threshold or Criteria: +/- 4.00 +/- 4.00 +/- 4.00 +/- <br /> Test Result: Pass Pass Pass <br /> Comments - (include information on repairs made prior to testing, and reconrnended follow-rep for*failed tests) <br /> CERTIFICATION OF TECIINICIAN 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 : Aw. Date : 2/ 12/2020 <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: 2344033 <br /> s <br /> I <br />