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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 four: 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 208118 N-4087- 1 -3 Date of Testing : 1/ 17/2019 <br /> Facility Address : 3355 E. HAMMER LANE @ HOLMAN RD, STOCKTON, CA 95212 <br /> Facility Contact: MANAGER Phone: 209 477-3699 <br /> Date Local Agency Was Notified of Testing : 1/ 17/2019 <br /> Name of Local Agency Inspector (if present during testing): enviormental <br /> 2 . TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY INC. <br /> Technician Conducting Test : Brent Bowen <br /> Credentials ) : W- CSLB Contractor W ICC Service Tech. W SWRCB Tank Tester r- Other (Specify) <br /> License Number(s) : 74360 <br /> 3 . SPILL BUCKET TESTING INFORMATION <br /> Test Method Used By : Hydrostatic P Vacuum Other <br /> Test Equipment Used : VACUUM TEST Equipment Resolution : 0 . 1 gph <br /> Identify Spill Bucket (By Tank Spill Box # Tank Tl Spill Box # Tank T2 <br /> i SUPREME - Fill 1 - Direct - REGULAR - Fill 1 - Direct - Spill Box # Spill Box # <br /> Number, Stored Product, etc.) Grade level Grade level <br /> f: Direct Bury r+` Direct Bury (' 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: 12.00 12.00 <br /> Bucket Depth : 14.00 14.00 <br /> Wait time between applying 1 min 1 min min min <br /> vacuum/water and start of test <br /> Test Start Time (Tt): 09:00:00 09:05 :00 <br /> Initial Reading (Ri): -30.00 in. H2O -30.00 in. H2O <br /> F Test End Time(TF): 09:01 :00 09:06:00 <br /> Final Reading (RF): -30.00 in. H2O -30.00 in. H2O <br /> Test Duration(TF—TI ): 1 min 1 nun <br /> Change in Reading (RF—RI) : 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 testing, and recommended follow- :ip for failed tests) <br /> CERTIFICATION OF TECIINICIAN RESPONSIBLE FOR CONDUCTING TMS 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 : *�% Date : 1/ 17/2019 <br /> 1 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 : 2339111 <br />