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y ../ `i Eca l�ltl <br /> Spill Bucket Testing Report Form MAR 0 4 2015 <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 regufa'?WR NMENTA 1 <br /> .. �..vv_71Y1-CT IpVr1^/T'1L <br /> I.FACILITY INFORMATION <br /> Facility 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): <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 /> Test Method Used By: r Hydrostatic rv— Vacuum Other <br /> 'rest Equipment Used: VACUUM TEST Equipment Resolution:0.1 gph <br /> Identify Spill Bucket(By Tank <br /> Spill Box#Tank TI Spill Box#Tank T2 PLUS- <br /> Spill Box#Tank T3 <br /> ,Number, Stored Product, etc.) SUPREME-Fill l-Direct- Fill 1-Direct-Grade level REGULAR e l I-Direct- Spill Box# <br /> Grade level GradGrnde level <br /> r Direct Bury r Direct Bury (I Direct Bury P Direct Bury <br /> Bucket Installation Type: IT Contained in Sump li Contained in Sump G Contained in Sump F:3 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 /> Test 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 1 min I min <br /> Change in Reading(RF—RI): -1.00 in.HG 0.00 in.HG 0.00 in.HG <br /> Pass/Fail 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 failed 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: '%'Y Date: 2/17/2015 <br /> 1 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 2321580 <br />