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0 <br />0 <br />SVVRCB, January 2006 <br />PINl�TACLE Spill Bucket Testing Report Form <br />This form is intended for use by contractors performing annual testing of USTspill containment structures. The completed form and printouts from <br />tests (ifapplicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1- FACILITY INFORMATION <br />Facility Name: Lathrop Chevron date of Testing: 12/16/2013 <br />Facility Address: 140 Lathrop Rd, Lathrop, Ca. 95330 <br />Facility Contact: Owner -Jesse Phone: (209)982-5005 <br />Name of Local Agency Inspector (Ypresent during testingf. Thuy Trail <br />2- TESTING CONTRACTOR INFORMATION <br />Company Name: Pinnacle Fuel Compliance Services, Inc. <br />Technician Conducting Test: Jeff Conger <br />Credentials': Z CSLB Contractor ® ICC Service Tech. ❑ SWRCB Tank Tester []Other (Specify) <br />License Number(s): ICC# -UT 1081782 CSLB# 894932 <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: ®Hydrostatic ❑Vacuum ❑Other <br />Test Equipment Used: Tape Measure, Stop Watch Equipment Resolution: 1116" <br />-� <br />Identity Spill Bucket (By Tank <br />Number, ,StoredProduct, etc. <br />#1 -Diesel #2 -Regular #3 -Premium <br />__T <br />Direct Bury Direct Bury Direct Bury <br />Bucket Installation Type: <br />Direct Bu /Sum <br />Bucket Diameter: <br />13" 13" 13" <br />Bucket Depth: <br />12" 12" 12" <br />Wait time between applying <br />vacuum/water and start of test: <br />10 mins 10 mins 10 mins <br />Test Start Time (Ti): <br />13:58 13:58 13:58 <br />Initial Reading (Ri): <br />11 Y2" 11 518" 11 W, <br />Test End Time (TF): <br />14:58 14:58 14:58 <br />Final Reading (RF): <br />11 '/2" 11 5/8" 11 '/" <br />Test Duration (TF -T,): <br />60 mins 60 mins 60 mins <br />Change in Reading (RF -Ri): <br />0 0 0 <br />Dass/Fail Threshold or Criteria: <br />1/16" - 60 mins 1116" - 60 mins 1/16" - 60 mins <br />Test Result: Pass/Fail <br />PASS PASS PASS <br />Com ments -(Include information on repairs made prior to resting, and recommended follow-up for faifed tests) <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />/ hereby certify that all the information contained in Mis report is t*ue, accurate, and in full compliance with legal mquirements. <br />Technician's Signature: Date: 1 211 61201 3 <br />State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more <br />stringent. <br />