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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 (fapplicable), 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 Date of Testing: 3/25/2015 <br /> Facility Address: 2615 W.Grant Line Tracy,Ca.95304 <br /> Facility Contact: Linda Phone: 209-836-3464 <br /> Date Local Agency Was Notified of Testing: 0 a- <br /> Name of Local Agency Inspector(fpresent during testing): Michelle Henry <br /> 2. TESTING CONTRACTOR INFORMATION <br /> APR 3 0 2015 <br /> Company Name: Reliable Petroleum Services, Inc. -VOWEL <br /> Technician Conducting Test: Guadalupe Sanchez HEA"'4!deo flT, <br /> Credentials': x CSLB Contractor x ICC Service Tech. ❑SWRCB Tank Tester ❑Other(Spec) <br /> License Number(s): 883706 5250451-UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: xHydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used: Standard Tape Measure Equipment Resolution: N/A <br /> Identify Spill Bucket (By Tank 1 T1: 91 Fill 2 T2: Diesel Fill 3 T3: 87 Fill 4 T4: <br /> Number, Stored Product, etc.) <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 x Contained in Sum <br /> Bucket Diameter: 12" 12" 12" <br /> Bucket Depth: 14" 103," 151/4" <br /> Wait time between applying I minute I minute 1 minute <br /> vacuum/water and start of test: <br /> Test Start Time(TI): 12:00 p.m. 12:00 p.m. 1:23 p.m. <br /> Initial Reading(RI): 12 1/8" 91/411 13 5/8" <br /> Test End Time(TF): 1:00 P.M. 1:00 P.M. 2:23 p.m. <br /> Final Reading(RF): 12 1/8" 9 '/a" 13 5/8" <br /> Test Duration(TF-Tj): 1 minute 1 hr 1 hr <br /> Change in Reading(RF-Rj): 0 0 0 <br /> Pass/Fail Threshold or 1/16" 1/16" 1/16" <br /> Criteria: <br /> Test Result: Pass x Fail x Pass ❑ Fail x Pass ❑ Fail Pass ❑ Fail <br /> Comments-(include information on repairs shade prior to testing, and recommended follow-up for failed tests) <br /> Replaced drain valve O-ring in the 87 fill box <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�d'�P � Date 3/25/2015 <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 />