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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 fora: 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 /> Facility Name: CHEVRON 210997 (N4693) Date of Testing : 1/ 17/2019 <br /> Facility Address : 1442A COLONY DR. , RIPON, CA 95366 <br /> Facility Contact: PATTY Phone : 209-599-0149 <br /> Date Local Agency Was Notified of Testing : 1 / 14/2019 <br /> Name of Local Agency Inspector (ifpresent during testing): ZUNA <br /> 2 . TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY INC. <br /> Technician Conducting Test: Jesus Saldivar <br /> Credentialsl : r CSLB Contractor F ICC Service Tech. r SWRCB Tank Tester Other (Specify) <br /> License Number(s) : <br /> 3 . SPILL BUCKET TESTING INFORMATION <br /> Test Method Used By : Hydrostatic Vacuum Other <br /> Test Equipment Used : LAKE TEST Equipment Resolution : 0.0625 in. <br /> Spill Box # Tank Spill Box # Tank <br /> Identify Spill Bucket (By Tank TI : SUPREMEUNLEADED T2:REGULARUNLEADED <br /> Number, Stored Product, etc.) PREMIUM - Fill 1 - Direct - REGULAR - Fill 1 - Direct - Spill Box # Spill Box # <br /> Grade level in containment Grade level in containment <br /> sump sump <br /> r Direct Bury r Direct Bury <br /> Bucket Installation Type : r Direct Bury f Direct Bury (` Contained in Sump r Contained in Sump <br /> i <br /> !+ Contained in Sump f+ Contained in Sump <br /> Bucket Diameter: 14.00 14.00 <br /> Bucket Depth : <br /> 11 .00 11 .00 <br /> Wait time between applying <br /> min min <br /> vacuum/water and start of test 5 min 5 min <br /> Test Start Time (Tj): <br /> 09:00:00 09:00:00 <br />` Initial Reading (Rj): <br /> 11 .00 in. H2O 11 .00 in. H2O <br /> Test End Time(Tp): <br /> 10:00:00 10:00:00 <br /> Final Reading (RF): <br /> 11 .00 in. H2O 11 .00 in. H2O <br /> Test Duration(TF—T, ): <br /> 1 hr 1 hr <br /> Change in Reading (RF—Rj) : <br /> 0.00 in. H2O 0.00 in. H2O <br /> Pass/Fail Threshold or Criteria: +/- +/- <br /> +/- 0.00 +/- 0.00 <br /> Test Result <br /> Pass Pass <br /> CommentS - (include information on repairs made prior to testing, and i4eco»znrended follow-zip for failed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the inforntation contained in this report is true, accurate, and in full compliance with legal requirements. <br /> Technician's Signature : � « Date : 1 / 17/2019 <br /> ' 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 : 2339114 <br />