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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(tfapplicable), should be provided to thefacilfty owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: TRACY CHEVRON Date of Te 2-21-1,7 <br /> Facility Address: 3775 TRACY BLVD TRACY CA 95376 a• i <br /> Facility Contact: Phone: 836-942 <br /> Date Local Agency Was Notified of Testing:2-10-17 <br /> Name of Local Agency Inspector(tfpresent during testing): GARRET <br /> 2.TESTING CONTRACTOR INFORMATION ENVIRONMr^.'d I AL HEALTH <br /> Company Name: AFFORDA TEST 4162 n1 Street Galt,CA 95632 (209)744-016F'az:'( 9)744-0116 <br /> Technician Conducting Test: ❑ Lyle D.Nimmo ❑ Zane A.Nimmo ® David A. Winkler ❑ Felix G. Ramirez <br /> 5249115-UT 5263322-UT 5263373-UT 5273934-UT <br /> Credentials': ®ICC Service Tech. ® S WRCB Tank Tester <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br /> Test Equipment Used: h20 and tape measure Equipment Resolution 1 X16 <br /> Identify Spill Bucket(By Tank 1 87 2 91 3 89 ; <br /> Number, Stored Product, etc. <br /> ❑ Direct Bury ❑ Direct Bury <br /> Bucket Installation Type: ❑Direct Bury ❑ Direct Bury ® Contained in ❑ Contained in <br /> ®Contained in Sump ®Contained in Sump <br /> Sum Sum <br /> Bucket Diameter: 11 11 11 <br /> Bucket Depth: 14 14 14 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 9 9 9 <br /> Initial Reading(RI): 14 14 14 <br /> Test End Time(TF): 10 10 10 <br /> Final Reading(RF): 14 14 14 <br /> Test Duration(TF—Ti): 1 H R IHR IHR <br /> Change in Reading(RF-R,): 0 0 0 <br /> Pass/Fail Threshold or 1/16 1/16 1/16 <br /> Criteria: <br /> Test Result: ® Pass ❑Fail ® Pass ❑ Fail ® Pass ❑ Fail i ❑ Pass ❑ Fail <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 /> 1 hereby certify that all the information contailned in this report is true,accurate,and in full compliance with legal requirements. <br /> }�� <br /> Technician's Signature: �I � aiDate 2-21-17 <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 />