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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 499840(N31) Date of Testing: 11/12/2019 <br /> Facility Address:4344 E WATERLOO RD @ 99,STOCKTON,CA 95215 <br /> Facility Contact:MANAGER Phone:209-931-2186 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name:TANKNOLOGY INC. <br /> Technician Conducting Test:Jarrod Cooke <br /> Credentials[: rl CSLB Contractor (Ji ICC Service Tech. r-1 SWRCB Tank Tester r— Other(Specify) <br /> License Number(s):8155550 <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used By: r Hydrostatic r Vacuum r Other <br /> Test Equipment Used:VACUUM TEST Equipment Resolution:0.1 gph <br /> Identify Spill Bucket(By Tank Spill Box#Tank T 1 Spill Box#Tank T2 REG <br /> Number,Stored Product, etc) SUPREME-Fill 1-Direct- UNLEAD-Fill 1-Direct- Spill Box# Spill Hoax <br /> Grade level Grade level <br /> C: Direct Bury f: Direct Bury r Direct Bury r Direct Bury <br /> Bucket Installation Type: r Contained in Sump r Contained in Sump r Contained in Sump r Contained in Sump <br /> Bucket Diameter: 11.50 11.50 <br /> Bucket Depth: 14.25 14.25 <br /> Wait time between applying <br /> vacuum/water and start of test 0 min 0 min min min <br /> Test Start Time(Tl): 09:16:00 09:19:00 <br /> Initial Reading(Rl): 30.00 in.H2O 30.00 in.H2O <br /> Test End Time(TF): 09:17:00 09:20:00 <br /> Final Reading(RF): 30.00 in.H2O 30.00 in.H2O <br /> Test Duration(TF—Tl): 1 min I min <br /> Change in Reading(RF—Rl): 0.00 in.H2O 0.00 in.H2O <br /> Pass/Fail Threshold or Criteria: +/-4.00 +/-4.00 +/- <br /> Test Result: Pass Pass <br /> Comments-(include information on repairs made prior to lesling, and recommended follow-up for failed tests) <br /> CERTIFICATION OF TECHMCIAN 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: 17�� Date: 11/12/2019 <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 /> WO:2342789 <br />