Laserfiche WebLink
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 210997(N-4693) Date of Testing: 1/12/2022 <br /> Facility Address: 1442A COLONY DR.,RIPON,CA 95366 <br /> Facility Contact: Diane Province Phone:209-5990149 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name:TANKNOLOGY INC. <br /> Technician Conducting Test:Jarrod Cooke <br /> Credentials): F- CSL13 Contractor ICC Service Tech. r SWRCB Tank Tester r— Other(Specify) <br /> License Number(s): 8155550 <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 /> Spill Box#Tank Spill Box#Tank <br /> Identify Spill Bucket(By Tank TLSUPREMEUNLEADED T2:REGULARUNLEADED <br /> Number,Stored Product, etc.) <br /> PREMIUM-Fill 1 -Direct- REGULAR-Fill 1-Direct- Spill Box# Spill Box# <br /> Grade level in containment Grade level in containment <br /> sump sump <br /> C Direct Bury f Direct Bury <br /> Bucket Installation Type: C Direct Bury C Direct Bury r Contained in Sump r Contained in Sump <br /> C: Contained in Sump (: Contained in Sump <br /> Bucket Diameter: <br /> 14.00 14.00 <br /> Bucket Depth: <br /> 15.00 15.00 <br /> Wait time between applying <br /> min min <br /> vacuum/water and start of test 0 min 0 min <br /> Test Start Time(Tl): <br /> 09:10:00 09:14:00 <br /> Initial Reading(Rl): <br /> 30.00 in.H2O 30.00 in.H2O <br /> Test End Time(TF): <br /> 09:11:00 09:15:00 <br /> Final Reading(RF): <br /> 28.00 in.H2O 27.00 in.H2O <br /> Test Duration(TF—Tl): <br /> 1 min 1 min <br /> Change in Reading(RF—Rl) <br /> -2.00 in.H2O -3.00 in.H2O <br /> Pass at Threshold or Criteria: <br /> +/-4.00 +/-4.00 <br /> Test Result: <br /> Pass Pass <br /> Comments-(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> CERTIFICATION OF TECI3NICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the inf/orrmation contained in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: 1/��� Date: 1/12/2022 <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:2353218 <br />