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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 Date of Testing: 24-09 <br /> Facility Address: 3400 MACARTHUR <br /> Facility Contact: KAMAR Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(ifpresent during testing): MICHELLE HENRY <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: CENTRAL PETROLEUM <br /> Technician Conducting Test: GREGG GELTZ <br /> Credentials: ❑CSLB Contractor X ICC Service Tech. ❑SWRCB Tank Tester 11 Other(Specify) <br /> License Number(s): 5250561-UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: X Hydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used: WATER—TAPE MEASURE Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1 87 UNL 2 91 UNL 3 DIESEL 4 <br /> Number, Stored Product, etc. <br /> Bucket Installation Type: ❑Direct Bury ❑Direct Bury ❑Direct Bury ❑Direct Bury <br /> X Contained in Sump X Contained in Sump X Contained in Sump ❑Contained in Sum <br /> Bucket Diameter: 14" 14" 14" <br /> Bucket Depth: 14 14" 14" <br /> Wait time between applying 5 MINS 5 MINS 5 MINS <br /> vacuum/water and start of test: <br /> Test Start Time(T,): 1;50 200 210 <br /> Initial Reading(R,): 12 12" 12" <br /> Test End Time(TF): 2:50 300 310 <br /> Final Reading(RF): 12" 12" 12" <br /> Test Duration(TF—T,): 1 HR 1 HR 1 HR <br /> Change in Reading(RF-R,): O O O <br /> Pass/Fail Threshold or <br /> Criteria: 1/16" PER HR 1/16" PER HR 1/16" PER HR <br /> Test Result: X Pass ❑Fail X Pass ❑Fail X Pass ❑Fail ❑ Pass ❑Fail <br /> COMMents— (include information on repairs made prior to testing and recommended follow-up for failed tests) <br /> ALL PASSED 1 HR TESTING <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> 1 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: <br /> State laws and regulations do not currently require tes ' e performed by a qualified contractor.However, local requirements <br /> may be more stringent. <br />