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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 201761 Date of Testing: 1/5/2024 <br /> Facility Address: 1103 S.MAIN ST.PERMIT NUMB.N-3315,MANTECA,CA 95337 <br /> Facility Contact:Diane Province Phone:209-8250174 <br /> Date Local Agency Was Notified of Testing: 1/1/2024 <br /> Name of Local Agency Inspector(if present during testing):KRISTINA <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name:TANKNOLOGY INC. <br /> Technician Conducting Test:Landon Zamora <br /> Credentials l: r— CSLB Contractor 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 R Vacuum F Other <br /> Test Equipment Used:VACUUM TEST Equipment Resolution:0.1 gph <br /> Spill Box#Tank Tl Spill Box#Tank T2 Regular Spill Box#Tank T3 Regular <br /> Identify Spill Bucket(By Tank Supreme SUPREME-Fill 1 2 REGULAR-Fill 1-Direct 1 REGULAR-Fill 1-Direct Spill Box# <br /> Number, Stored Product, etc) -Direct-Grade level in -Grade level in -Grade level in <br /> containment sump containment sump containment sump <br /> Bucket Installation Type: rDirect Bury C Direct Bury r Direct Bury C Direct Bury <br /> C: Contained in Sump C Contained in Sump C: Contained in Sump C Contained in Sump <br /> Bucket Diameter: 12.00 12.00 12.00 <br /> Bucket Depth: 16.00 16.00 16.00 <br /> Wait time between applying 1 min 1 min 1 min min <br /> vacuum/water and start of test <br /> Test Start Time(TI): 08:00:00 08:05:00 08:10:00 <br /> Initial Reading(RI): 30.00 in.1420 30.00 in.H2O 30.00 in.H2O <br /> Test End Time(TF): 08:01:00 08:06:00 08:11:00 <br /> Final Reading(RF): 30.00 in.H2O 30.00 in.H2O 30.00 in.H2O <br /> Test Duration(TF—TI): 1 min 1 min 1 min <br /> Change in Reading(RF—RI): 0.00 in.H2O 0.00 in.H2O 0.00 in.H2O <br /> Pass/Fail Threshold or Criteria: +/-4.00 +/-4.00 +/-4.00 +/- <br /> Test Result: Pass Pass Pass <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: 1/5/2024 <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:2363808 <br />