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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: Lower Sac Chevron Date of Testing: 03/03/2011 <br /> Facility Address: 8660 Lower Sacramento Rd. Stockton,Ca.95210 <br /> Facility Contact: Kamal Phone: 209-477-2844 <br /> Date Local Agency Was Notified of Testing: Q,2_ 2$-1A iI <br /> Name of Local Agency Inspector(fpresent during testing): Garrett <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(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: <br /> Identify Spill Bucket(By Tank 1 Tl:91 Fill 2 T2:89 Fill 3 T3: 87 Fill 4 T4: <br /> Number, Stored Product, etc. <br /> Bucket Installation Type: x Direct Bury x Direct Bury x Direct Bury Direct Bury <br /> ❑Contained in Sump ❑Contained in Sump ❑Contained in Sump ❑Contained in Sum <br /> Bucket Diameter: 12" 12" 12" <br /> Bucket Depth: 131/4" 131/4" 123/4" <br /> Wait time between applying 1 minute 1 minute 1 minute <br /> vacuum/water and start of test: <br /> Test Start Time(TI): 10:52 a.m. 10:52 a.m. 10:53 a.m. <br /> Initial Reading(RI): 12" 12" 117/8" <br /> Test End Time(TF): 11:52 a.m. 11:52 a.m. 11:53 a.m. <br /> Final Reading(RF): 12" 12" 117/8" <br /> Test Duration(TF—TI): 1 hr 1hr 1 hr <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 T 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 the information contained in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: Date 08-27-2010 <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 />