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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 372736 Date of Testing: 2/11/2021 <br />Facility Address: 9484 West Lane , Stockton, CA 95210 <br />Facility Contact: Diane Province Phone: 209-4749825 <br />Date Local Agency Was Notified of Testing: 2/11/2021 <br />Name of Local Agency Inspector (if present during testing): paul <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: TANKNOLOGY INC. <br />Technician Conducting Test: Jesus Saldivar <br />Credentials1 : CSLB Contractor ICC Service Tech. SWRCB Tank Tester Other (Specify) <br />License Number(s): <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used By: Hydrostatic Vacuum Other <br />Test Equipment Used: VACUUM TEST Equipment Resolution: 0.1 gph <br /> <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />Bucket Installation Type: <br />Bucket Diameter: <br />Bucket Depth: <br />Wait time between applying <br />vacuum/water and start of test <br />Test Start Time (TI): <br />Initial Reading (RI): <br />Test End Time(TF): <br />Final Reading (RF): <br />Test Duration(TF–TI): <br />Change in Reading (RF–RI) : <br />Pass/Fail Threshold or Criteria: <br />Test Result: <br />Spill Box # Tank T1 <br />SUPREME - Fill 1 - Direct - <br />Below Grade in <br />containment sump <br /> Direct Bury <br /> Contained in Sump <br />12.00 <br />16.00 <br />1 min <br />08:00:00 <br />30.00 in. H20 <br />08:01:00 <br />30.00 in. H20 <br />1 min <br />0.00 in. H20 <br />+/- 4.00 <br />Pass <br />Spill Box # Tank T2 <br />REGULAR - Fill 1 - Direct - <br />Below Grade in <br />containment sump <br /> Direct Bury <br /> Contained in Sump <br />12.00 <br />16.00 <br />1 min <br />08:02:00 <br />30.00 in. H20 <br />08:03:00 <br />30.00 in. H20 <br />1 min <br />0.00 in. H20 <br />+/- 4.00 <br />Pass <br />Spill Box # Tank T3: diesel <br />Diesel - Fill 1 - Direct - <br />Below Grade in <br />containment sump <br /> Direct Bury <br /> Contained in Sump <br />12.00 <br />16.00 <br />1 min <br />08:04:00 <br />30.00 in. H20 <br />08:05:00 <br />30.00 in. H20 <br />1 min <br />0.00 in. H20 <br />+/- 4.00 <br />Pass <br />Spill Box # <br /> Direct Bury <br /> Contained in Sump <br /> <br /> <br /> min <br /> <br /> <br /> <br /> <br /> <br /> <br />+/- <br /> <br />Comments - (include information on repairs made prior to testing, and recommended follow-up for failed tests) <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 full compliance with legal requirements. <br />Technician's Signature:Date:2/11/2021 <br />1State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more stringent. <br />WO: 2348241