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0 9 <br />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 />I _ FA f iI tTv INFORMATION <br />Facility Name: Morada Chevron Date of Testing: 1127112 <br />Facility Address: 10879 N. Hwy 99 <br />Facility Contact: Billal Phone: 209-931-6154 i <br />Date Local Agency Was Notified of Testing: 1/23/12 <br />Name of Local Agency Inspector (if present during testing): Garrett Backus <br />'IPV.q TNV CONTRACTOR INFORMATION <br />Company Name: Nucleus Pump Services <br />Technician Conducting Test: Ronnie Lewis <br />Credentials: X CSLB Contractor X ICC Service Tech. [1 SWRC13 Tank Tester ❑ Other (specify) <br />License Number(s): ICC #8032737 <br />v fiPII .I , BUCKET TESTING INFORMATION <br />Test Method Used: X Hydrostatic 0 Vacuum ❑ Other <br />Test Equipment Used: Water H2O Measure Tape <br />Identify Spill Bucket (By Tank 1- Super r 2- Plus <br />Number, Stored Produce, etc. <br />Equipment Resolution: <br />3- Regular 4- Diesel <br />Bucket Installation Type: <br />X Direct Bury <br />Contained in Sump <br />X Direct Bury <br />Contained in Sump <br />X Direct Bury <br />Contained in Sump <br />X Direct Bury <br />Contained in Sum <br />Bucket Diameter: <br />11" <br />11 <br />11" <br />11" <br />Bucket Depth: <br />12" <br />12" <br />1.2" <br />13" <br />Wast time between applying <br />vacuum/water and start of test: <br />5 Min <br />5 Min <br />5 Min <br />5 Min <br />Test Start Time (Tl): <br />11:15 <br />11:15 <br />11:15 <br />11: i 5 <br />Initial Reading (R6): <br />10,75 <br />11.5 <br />10.5 <br />13.5 <br />Test End Time (TF): <br />13:30 <br />12:15 <br />12:15 <br />12:15 <br />Final Reading (RF): <br />10.75 <br />11.5 <br />10.5 <br />13.5 <br />Test Duration (TF — Tj): <br />1 Hour <br />1 Hour <br />1 Hour <br />1 Hour <br />ry�011On <br />Change in Reading t+�F-RI): <br />� <br />0i1 <br />/rp <br />Pass/Fail Threshold or <br />Criteria: <br />Drop In Water Ht. <br />Drop In Water Ht. <br />Drop In Water Ht <br />Drop In Water Ht <br />Test Result: <br />X Pass ❑ Fail <br />X Pass ❑ Fail <br />X Pass Fall <br />X Pass ❑ Fail <br />_Comments — (include information on repairs made prior to testing and recommended follow-up for failed tests) <br />T1 Suver Drop In Water. Replace fill Cap and tightened drain valve bolts. <br />Retest and found passed second test. <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />! hereby certify that all the information contained in this report is true, accurate, and in full compliance with legal requirements. <br />State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements <br />may be more stringent. <br />