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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(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: 1/15/2020 <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: <br /> Name of Local Agency Inspector(if present during testing): <br /> 2.TESTING CONTRACTOR INFORMATION iai;CGIN/En <br /> Company Name:TANKNOLOGY INC. <br /> Technician Conducting Test:Jarrod Cooke <br /> Credentials): r' CSLB Contractor r�' ICC Service Tech. r7 SWRCB Tank Tester r- Other(Specify) <br /> License Number(s):8155550 H <br /> 3.SPL BUCKET TESTING INFORMATION )F PART M P <br /> ILN T <br /> Test Method Used By: r Hydrostatic r• Vacuum 7 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 T1:SUPREME UNLEADED T2:REGULAR UNLEADED <br /> Number,Stored Product, etc.) <br /> 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 /> (` Direct Bury r Direct Bury <br /> Bucket Installation Type: r Direct Bury r Direct Bury (' Contained in Sump r Contained in Sump <br /> f: Contained in Sump t: Contained in Sump <br /> Bucket Diameter: <br /> 14.00 14.00 <br /> Bucket Depth: <br /> Wait time between applying 11.00 11.00 <br /> min min <br /> vacuum/water and start of test 5 min 5 min <br /> Test Start Time(Tl): <br /> 09:55:00 09:55:00 <br /> Initial Reading(Rl): <br /> 10.50 in. 11.00 in. <br /> Test End Time(TF): <br /> 10:55:00 10:55:00 <br /> Final Reading(RF): <br /> 10.50 in. 11.00 in. <br /> Test Duration(TF—Tl): <br /> 1 hr 1 hr <br /> Change in Reading(RF—RI): <br /> 0.00 in. 0.00 in. <br /> Pass/Fail Threshold or Criteria: +/-+/-0.00 /-0.00 <br /> Test Result: <br /> Pass Pass <br /> Comments-(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> CERTIFICATION OF TECIINICIAN 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: 1/15/2020 <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:2343362 <br />