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SWRCB, January 2006 <br /> Spill Bucket Testing Report Form <br /> This forma is intended for use by contractors performing annual testing of UST spill containment structures. The completed form and <br /> printouts fr4orn 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 212470 Date of Testing : 2/21 /2019 <br /> Facility Address : 3400 N MacArthur Drive , Tracy, CA 95376 <br /> rn <br /> Facility Contact: Phone : <br /> Date Local Agency Was Notified of Testing : 2/ 18/2019 <br /> Name if 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 ) : ry CSLB Contractor W ICC Service Tech. r' SWRCB Tank Tester r Other (Specify) <br /> License Number(s) : <br /> 3 . SPILL BUCKET TESTING INFORMATION <br /> Test Method Used By : Hydrostatic I' Vacuum Other <br /> Test Equipment Used : LAKE TEST Equipment Resolution: 0.0625 in. <br /> Spill Box # Tank REG Spill Box # Tank Spill Box # Tank Diesel - <br /> Identify Spill Bucket (By Tank UNLEAD - Fill 1 - Direct - PREMIUM - Fill 1 - Direct - Fill I - Direct - Grade level Spill Box # <br /> Number, Stored Product, etc.) Grade level in containment Grade level in containment in containment sump <br /> sump sump <br /> r Direct Bury (' Direct Bury r Direct Bury r Direct Bury <br /> Bucket Installation Type : (* Contained in Sump f+ Contained in Sump f* Contained in Sump r Contained in Sump <br /> Bucket Diameter: 12.00 12.00 12.00 <br /> Bucket Depth: 12.00 10.00 10.00 <br /> Wait time between applying 5 min 5 min 5 min min <br /> vacuum/water and start of test <br /> Test Start Time (Tl): 09:00:00 09:00:00 09:00:00 <br /> Initial Reading (Rl): 12.00 in. H2O 10.00 in. H2O 10.00 in. H2O <br /> Test End Tirne(TF): 10:00:00 10:00:00 10:00:00 <br /> Final Reading (RF): 12.00 in. H2O 10.00 in. H2O 10.00 in. H2O <br /> Test Duration(TF—TI): 1 hr I hr 1 hr <br /> Change in Reading (RF—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 Fail Pass <br /> Comments - (include information on repairs made prior to testing, and recommended follow- up for• failed tests) <br /> 91 SPILL BUCKET DIDNT FILL THE FIVE GALLON CAPACITY. . .. <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 : /�" 4 Date: 2/21 /2019 <br /> r 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 : 2338334 <br />