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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 210997(N-4693) Date of Testing: 1/19/2023 <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: 1/16/2023 <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:TANKNOLOGY INC. <br /> Technician Conducting Test:Landon Zamora <br /> Credentials l: r CSLB Contractor rv— 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 W Vacuum F 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 T1:SUPREMEUNLEADED T2:REGULARUNLEADED <br /> Number, Stored Product, etc.) <br /> PREMIUM-Fill 1-Direct- REGULAR-Fill 1-Direct- Spill Box# Spill Box# <br /> �1 <br /> Grade level in containment Grade level in containment <br /> sump sump <br /> r Direct Bury C Direct Bury <br /> Bucket Installation Type: r Direct Bury r Direct Bury r Contained in Sump C Contained in Sump <br /> C: Contained in Sump (: Contained in Sump <br /> Bucket Diameter: <br /> 12.00 12.00 <br /> Bucket Depth: <br /> 16.00 16.00 <br /> Wait time between applying <br /> vacuum/water and start of test 1 min 1 min min mm <br /> Test Start Time(TI): <br /> 08:30:00 08:35:00 <br /> Initial Reading(Rl): <br /> 30.00 in.1420 30.00 in.H2O <br /> Test End Time(TF): <br /> 08:31:00 08:36:00 <br /> Final Reading(RF): <br /> 30.00 in.H2O 30.00 in.H2O <br /> Test Duration(TF—Ti): <br /> 1 min 1 min <br /> Change in Reading(RF—R,) <br /> 0.00 in.H2O 0.00 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 TECIINICIAN 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: 1/19/2023 <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:2358232 <br />