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SWRCB, January 2006 <br />Spill Bucket Testing Report Form <br />This form is intended for use by contractors per forming annual testing of UST spill containment structures. The completed for nz and <br />printouts fr•orn tests (if applicable), should be provided to the facility oitmer/operatw• for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Name: CHEVRON 09840 (N31) 1 Date of Testing: 11/15/2018 <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): unknown <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: TANKNOLOGY INC. <br />Technician Conducting Test: Jarrod Cooke <br />---Credentials): r. CSLB Contractor F ICC Service Tech r' SWRCB Tank Tester r' Other (Specify) <br />License Number(s): <br />3. SPILL BUCKET TESTING INFORMATION 17 <br />Comments <br />Test Method Used By: Hydrostatic Vacuum Other <br />Test Equipment Used: LAKE TEST <br />Equipment Resolution: 0.0625 in. <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc) <br />Spill Box # Tank T1 <br />SUPREME - Fill 1 - Direct - <br />Grade level <br />Spill Box # Tank T2 REG <br />UNLEAD - Fill 1 - Direct - <br />Grade level <br />Spill Box # <br />Spill Box # <br />Bucket Installation Type: <br />r Direct Bury <br />r Contained in Sump <br />1'+ Direct Bury <br />r Contained in Sump <br />r Direct Bury <br />r Contained in Sump <br />�` Direct Bury <br />Contained in Sump <br />Bucket Diameter: <br />12.00 <br />12.00 <br />Bucket Depth: <br />14.00 <br />14.00 <br />Wait time between applying <br />vacuum/water and start of test <br />5 min <br />5 min <br />min <br />min <br />Test Start Time (TI): <br />09:36:00 <br />09:36:00 <br />Initial Reading (RI): <br />14.00 in. <br />13.25 in. <br />Test End Time(TF): <br />10:36:00 <br />10:36:00 <br />Final Reading (RF): <br />14.00 in. <br />13.25 in. <br />Test Duration(TF—Tt): <br />1 hr <br />1 hr <br />Change in Reading (RF—Rt): <br />0.00 in. <br />0.00 in. <br />Pass/Fail Threshold or Criteria: <br />+/- 0.00 <br />+/- 0.00 <br />+/- <br />+/- <br />Test Result: <br />Pass <br />Pass <br />- (include information on repairs made prior to testing, and recanmended follow-up for failed tests) <br />CERTIFICATION OF TECIINICIAN RESPONSIBLE FOR CONDUCTING THLS TESTING <br />I hereby certify that all the information contained in this report is true, accurate, and irz full compliance with legal rer�uirements. <br />Technician's Signature: Z <br />%�-'---"' <br />Date: 11/15/2018 <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: 2338477 <br />