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N .J <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 /> 1.FACILITY INFORMATION <br /> Facilitv Name:CHEVRON#98264(N-534) Date of Testing:2/17/2015 <br /> Facility Address:3775 N.TRACY BLVD,TRACY,CA 95376 <br /> Facility Contact:MGR-PAT Phone:209-836-9422 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(ifpresent during testing): _ 1TA <br /> " <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name:TANKNOLOGY INC. <br /> Technician Conducting Test: Ryan Casey <br /> Credentials): r CSLB Contractor r ICC Service Tech. r SWRCB Tank Tester r Other(Specify) <br /> License Number(s): <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> "Fest Method Used By: r Hydrostatic r Vacuum r Other <br /> Test Equipment Used:VACUUM TEST Equipment Resolution: 0.1 gph <br /> Identify Spill Bucket(By Tank Spill Box#Tank H Spill Box#Tank T2 PLUS- Spill Box#Tank T3 <br /> Number, Stored Product, etc.) SUPREME-Fill I -Direct- Fill I -Direct-Grade level REGULAR-Fill I -Direct- Spill Box# <br /> Grade level Grade level <br /> f Direct Bury r Direct Bury r Direct Bury t-' Direct Bury <br /> Bucket Installation Type: IT Contained in Sump IT Contained in Sump f*" Contained in Sump f Contained in Sump <br /> Bucket Diameter: 11.00 11.00 11.00 <br /> Bucket Depth: 12.50 12.00 12.50 <br /> Wait time between applying 5 min 5 min 5 min min <br /> vacuum/water and start of test <br /> "rest Start Time(TI): 09:00:00 09:01:00 09:02:00 <br /> Initial Reading(RI): 30.00 in.HG 30.00 in.HG 30.00 in.HG <br /> Test End Time(TF): 09:01:00 09:02:00 09:03:00 <br /> Final Reading(RF): 29.00 in.HG 30.00 in.HG 30.00 in.HG <br /> Test Duration(TF—TI): 1 min I min 1 min <br /> Change in Reading(RF—RI): -1.00 in.HG 0.00 in.FIG 0.00 in.HG <br /> Pass/Fai l Threshold or Criteria: +/-4.00 +/-4.00 +/-4.00 +/- <br /> Test Result: Pass. . Pass Pass <br /> Comments-(include information on repairs made prior to testing, and recommended follow-up for jailed 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: '"' "%' Date: 2/17/2015 <br /> State laws and regulations do not cuaently require testing to be performed by a qualified contractor.However,local requirements maybe more stringent. <br /> WO 2321580 <br />