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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 209167 Date of Testing:2/11/2021 <br /> Facility Address: 1234 E.YOSEMITE AVE @ SPRECKLES,MANTECA,CA 95336 <br /> Facility Contact: Diane Province Phone:209-8247433 <br /> Date Local Agency Was Notified of Testing: 1/21/2021 <br /> Name of Local Agency Inspector(if present during testing):SAN JOAQUIN CTY ENV <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name:TANKNOLOGY INC. <br /> Technician Conducting Test:Clint Fuhrman <br /> Credentials): F- CSLB Contractor R ICC Service Tech. r SWRCB Tank Tester r— Other(Specify) <br /> License Number(s): 9160945 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used By: Hydrostatic F Vacuum Other <br /> Test Equipment Used:VACUUM TEST Equipment Resolution:0.1 gph <br /> is <br /> Identify Spill Bucket(By Tank Spill Box#Tank T:I Spill Box#Tank T:2 <br /> Number,Stored Product, etc.) SUPREME-Fill 1 -Direct- REGULAR-Fill 1-Direct- Spill Box# Spill Box# <br /> Grade level Grade level <br /> • Direct Bury G Direct Bury C Direct Bury f Direct Bury <br /> Bucket Installation Type: 4 Contained in Sump r Contained in Sump 4 Contained in Sump 4 Contained in Sump <br /> Bucket Diameter: 12.00 12.00 <br /> Bucket Depth: 13.00 13.00 <br /> Wait time between applying <br /> 1 min 1 min min min <br /> vacuum/water and start of test <br /> Test Start Time(Tl): 10:15:00 10:18:00 <br /> Initial Reading(Rl): 30.00 in.H2O 30.00 in.H2O <br /> Test End Time(TF): 10:16:00 10:19:00 <br /> Final Reading(RF): 30.00 in.H2O 30.00 in.H2O <br /> Test Duration(TF—Tl): 1 min 1 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 testing, and recommended follow-up for failed tests) <br /> CERTIFICATION OF TECI INICIAN 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: l�`��✓^ Date: 2/11/2021 <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:2348227 <br />