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0 0 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:/ /27/2015 <br />Facility Address: 1442A COLONY DR., RIPON, CA 95366 <br />Facility Contact:PATTY Phone: 209-599-0149 <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (tf present during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: TANKNOLOGY INC. <br />Technician Conducting Test: Jarrod Cooke <br />Credcntialsl : M CSLB Contractor 7- ICC Service Tech. r -j SWRCB Tank Tester M Other (Specify) <br />License Number(s):5311523 <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used By: r Hydrostatic 7! Vacuum F Other <br />Test Equipment Used: VACUUM TEST Equipment Resolution: 0.1 gph <br />Identify Spill Bucket (By Tank <br />Number, Stared Product, etc.) <br />Number, <br />Spill Box #Tank <br />T1:SUPREN4E UNLEADED <br />PREtvIIi.JM -Fill ] -direct - <br />Grade level in containment <br />sump <br />Spill Box #Tank <br />T2:REGULAR UNLEADED <br />I REGULAR -Fill 1 -Direct - <br />Grade level in containment <br />sum <br />Spill Box # <br />Spill Box # <br />Bucket Installation Type: <br />Bucket Diameter: <br />r Direct Bury <br />Io Contained in Sump <br />Direct Bury <br />f Contained in Sump <br />r Direct Bury <br />G Contained in Sump <br />Q Direct Bury <br />C Contained in Sump <br />12.00 <br />12.00 <br />Bucket Depth: <br />12.00 <br />12.00 <br />Wait time between applying <br />vacuum/water and start of test <br />min <br />ruin <br />5 min <br />5 min <br />Test Start Time (TI): <br />09:20:00 <br />09:24:00 <br />Initial Reading (RI): <br />30.00 in. H2O <br />30.00 in. H2O <br />Test End Time(TF): <br />09:21:00 <br />09:25:00 <br />Final Reading (RF): <br />- <br />30.00 in. H2O <br />27.00 in. H2O <br />Test Duration(TF—Tl): <br />1 min <br />1 min <br />Change in Reading (RF–Rl) <br />0.00 in. H2O <br />-3.00 in. I320 <br />Pasi] °Threshold or Criteria: <br />- <br />+! <br />+/- 4.00 <br />+/-4.00 <br />Test Result: <br />Pn,ti <br />Pass <br />Comments - (include information on repairs made prior to testing, and recotnnaetided follow -tip for failele <br />r -• <br />VIRONMENT <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: 1/lr :7- <br />Date: 1/27/2015 <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: 2320972 <br />