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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 372736 Date of Testing: 2/ 19/2019 <br /> Facility Address: 9484 West Lane , Stockton, CA 95210 <br /> Facility Contact: Phone : - <br /> Date Local Agency Was Notified of Testing : 2/ 15/2019 <br /> Name of Local Agency Inspector (if present during testing): ZUNA <br /> 2 . TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY INC. <br /> Technician Conducting Test: Jesus Saldivar <br /> Credentials ) : r' 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 Vacuum Other <br /> Test Equipment Used : LAKE TEST Equipment Resolution: 0.0625 in. <br /> Spill Box # Tank 1 Spill Box # Tank 2 Spill Box # Tank T-3 diesel <br /> Identify Spill Bucket (By Tank UNLEADED - Fill I - 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 /> f Direct Buty tDirect Bury r' Direct Bury r` Direct Bury <br /> Bucket Installation Type : (: Contained in Sump C: Contained in Sump !+ Contained in Sump t Contained in Sump <br /> Bucket Diameter: 12.00 12.00 12.00 <br /> Bucket Depth: 13.00 12.00 12.00 <br /> Wait time between applying <br /> 5 min 5 min 5 min min <br /> vacuum/water and start of test <br /> Test Start Time (Tt): 09:00:00 09:00:00 09:00:00 <br /> Initial Reading (Rl): 13 .00 his H2O 12.00 in. 1420 12.00 in. H2O <br /> Test End Time(TF): 10:00:00 10:00:00 10:00:00 <br /> Final Reading (RF): 13 .00 in. H2O 12.00 in. H2O 12.00 in. H2O <br /> Test Duration(Tp--TI): I his 1 his 1 his <br /> Change in Reading (Rg-RI) : 0.00 in. H2O 0.00 in. H2O 0.00 in. H2O <br /> Pass/Fail Threshold or Criteria: +/- 0.00 +/" 0,00 +/- 0.00 +/- <br /> Test Result: Pass Pass Pass <br /> i <br /> Comments - (include information on repairs made prior to testing, and recofmnended 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 fill compliance with legal requirements. <br /> Technician's Signature : AV dl� Date : 2/19/2019 <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 /> t <br /> WO : 2338510 <br /> E <br /> i <br />