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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(f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: WEST VALLEY CHEVRON AUTO Date of Testing:03/05/012 <br /> Facility Address: 2615 W.Grantline Road,Tracy CA <br /> Facility Contact: Linda Mutnik Phone:209-836-3464 <br /> Date Local Agency Was Notified of Testing: 02-29-2012 <br /> Name of Loca] Agency Inspector(rf present during testing): Thuy Tran <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Reliable Petroleum Services Inc. <br /> Technician Conducting Test: Guadalupe Sanchez <br /> Credentials: X CSLB Contractor X ICC Service Tech. ❑SWRCB Tank Tester ❑Other(Specify) <br /> License Number(s): 883706 5250451-UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: X Hydrostatic 7 Vacuum .❑Other <br /> Test Equipment Used: Standard Tape Measure Equipment Resolution: <br /> Identify Spill Bucket(By Tank T1: Premium Fill T2: Diesel Fill Bucket T3: Regular Fill <br /> Number, Stored Product, etc. Bucket Bucket <br /> Bucket Installation Type: Direct Bury Direct Bury Direct Bury Direct Bury <br /> X Contained in Sump X Contained in Sump X Contained in Sump Contained in Sum <br /> Bucket Diameter: 12" 12" 12" <br /> Bucket Depth: 14" 14" 14" <br /> Wait time between applying <br /> vacuum/water and start of test: lmin. lmin. lmin. <br /> Test Start Time(Tj): 10:30a.m 10:30a.m 9:40a.m <br /> Initial Reading(Ri): .12'/4" 121/4" 13 7/16" <br /> Test End Time(TF): 11:30a.m 11:30a.m 10:40a.m <br /> Final Reading(RF): 12'/4" 12'/4" 13 7/16" <br /> Test Duration(TF—Tj): 1 hour 1 hour 1 hour <br /> Change in Reading(RF-Ri): 0 0 0 <br /> Pass/Fail Threshold or 1/16" 1/16" 1/16" <br /> Criteria: <br /> Test Result: X Pass ❑Fail X Pass ❑Fail X Pass ❑Fail ❑ 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 /> I hereby certify that all lite information contained in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: Date:03/05/2012 <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 />