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SWRCB, January 2006 <br />Spill Bucket Testing Report Form <br />This for•nr 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 />2. TESTING CONTRACTOR INFORMATION <br />3. SPILL BUCKET TESTING INFORMATION <br />Facility Name: CHEVRON # 94275 <br />Date of Testing: 2/2 1. 5/2019 <br />--lrvr <br />-- <br />Facility Address: 2905 W. BENJAMIN HOLT <br />@ I-5, STOCKTON, CA 95207 <br />Facility Contact: MGR-BELINDA (N-3254-5) Phone: 209478-5555 <br />Date Local Agency Was Notified of Testing: <br />2/22/2019 <br />Name of Local Agency Inspector (if present <br />during testing): UNKOWN <br />2. TESTING CONTRACTOR INFORMATION <br />3. SPILL BUCKET TESTING INFORMATION <br />Comlrients - (include information on repairs made prior to testing, and recommended follow-up for <br />CERTIFICATION OF TECI-INICIAN RESPONSIBLE FOR CONDUC'T'ING THIS TESTING f', >°� ,• <br />I hereby certify that all the inforntalion contained in this report is true, accurate, and in full compliance will: legal requirements. <br />Technician's Signature: a4)�r t4L <br />Date: 2/25/2019 <br />t 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: 2339344 <br />Test Method Used By: �j Hydrostatic � Vacuum �' Other <br />Test Equipment Used: VACUUM TEST <br />Equipment Resolution: 0.1 gph <br />Identify Spill Bucket (By Tank <br />Naanber, Stored Product, etc.) <br />Spill Box # Tank T2 REG <br />UNLEAD -Fill I - Direct - <br />Grade level in containment <br />sump <br />Spill Box # Tank T 1 <br />SUPREME- Fill 1 - Direct - <br />Grade level in containment <br />sump <br />Spill Box # Tank T3 <br />DIESEL2 - Fill 1 "Direct - <br />Grade level in contaimnent <br />sump <br />Spill Box # <br />Bucket Installation Type: <br />f Direct Bury <br />(; Contained in Sump <br />r Direct Bury <br />r: Contained in Sump <br />i Direct Bury <br />r+` Contained in Sump <br />(` Direct Bury <br />r Contained in Sump <br />Bucket Diameter: <br />12.00 <br />12.00 <br />12.00 <br />Bucket Depth: <br />12.00 <br />12.00 <br />12.00 <br />Wait time between applying <br />vacuum/water and start of test <br />I min <br />I min <br />1 min <br />min <br />Test Start Time (Tt): <br />09:00:00 <br />09:03:00 <br />09:05:00 <br />Initial Reading (RI): <br />30.00 in. H2O <br />30.00 in. H2O <br />30.00 in. H2O <br />Test End Time(TF): <br />09:01:00 <br />09:04:00 <br />09:06:00 <br />Final Reading (RF): <br />30.00 in. H2O <br />30.00 in. H2O <br />28.00 in. H2O <br />Test Duration(TF—T,): <br />I min <br />1 min <br />1 min <br />Change in Reading (RF—RI) : <br />0.00 in. H2O <br />0.00 in. H2O <br />-2.00 in. H2O <br />Pass/Fail Threshold or Criteria: <br />+/- 4.00 <br />+/- 4.00 <br />+/- 4.00 <br />+/- <br />Test Result: <br />Pass <br />Pass <br />Pass <br />Comlrients - (include information on repairs made prior to testing, and recommended follow-up for <br />CERTIFICATION OF TECI-INICIAN RESPONSIBLE FOR CONDUC'T'ING THIS TESTING f', >°� ,• <br />I hereby certify that all the inforntalion contained in this report is true, accurate, and in full compliance will: legal requirements. <br />Technician's Signature: a4)�r t4L <br />Date: 2/25/2019 <br />t 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: 2339344 <br />