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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 499840(N31) Date of Testing: 11/13/2025 <br /> Facility Address:4344 E WATERLOO RD @ 99,STOCKTON,CA 95215 <br /> Facility Contact:Diane Province Phone:209-9312186 <br /> Date Local Agency Was Notified of Testing: 11/13/2025 <br /> Name of Local Agency Inspector(if present during testing):UNNKOWN <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name:TANKNOLOGY INC. <br /> Technician Conducting Test:Jesus Saldivar <br /> Credentials1: r- CSLB Contractor V ICC Service Tech. r- SWRCB Tank Tester r- Other(Specify) <br /> Licensc 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 /> Identify Spill Bucket(By Tank Spill Box#Tank Premium Spill Box#Tank Regular <br /> Number, Stored Product, etc) SUPREME-Fill 1-Direct- REG UNLEAD-Fill 1- Spill Box# Spill Box# <br /> Grade level Direct-Grade level <br /> C: Direct Bury l* Direct Bury r Direct Bury C Direct Bury <br /> Bucket Installation Type: r Contained in Sump C Contained in Sump r Contained in Sump C Contained in Sump <br /> Bucket Diameter: 12.00 12.00 <br /> Bucket Depth: 14.00 14.00 <br /> Wait time between applying <br /> 1 min 1 min min min <br /> vacuum/water and start of test <br /> Test Start Time(TI): 09:00:00 09:02:00 <br /> Initial Reading(RI): 30.00 in.H2O 30.00 in.H2O <br /> Test End Time(TF): 09:01:00 09:03:00 <br /> Final Reading(RF): 30.00 in.H2O 30.00 in.H2O <br /> Test Duration(TF—TI): 1 min 1 min <br /> Change in Reading(RF—RI): 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 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: Al lea- Date: 11/13/2025 <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:2383551 <br />