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Spill Bucket Testing Report Form J A N 0 7 0 111 <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 ownerloperatorfor submittal to the local regulat7� <br /> q <br /> 1\1 M E N <br /> 1.FACILITY INFORMATION <br /> Facility Name:CHEVRON#99840 Date of Testing: 12/29/2015 <br /> Facility Address:4344 E WATERLOO RD g 99,STOCKTON,CA 95215 <br /> Facility Contact:MANAGER Phone:209-931-2186 <br /> Date Local Agency Was Notified of Testing: 12/29/2015 <br /> Name of Local Agency Inspector(if present during testing):Cindy Yo <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name:TANKNOLOGY INC. <br /> Technician Conducting Test:Brent Bowen <br /> Credentials]: r1:7 CSLB Contractor V ]CC Service Tech. 170 SWRCB Tank Tester r- Other(Specify) <br /> License Number(s):743160 <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used By: W Hydrostatic Vacuum Other <br /> Test Equipment Used:LAKE TEST Equipment Resolution:0.0625 in. <br /> 7777- <br /> Identify Spill Bucket(By Tank Spill Box#Tank TI Spill Box#Tank T2 REG <br /> Number, Stored Product, etc.) SUPREME-Fill I -Direct- UNLEAD-Fill I -Direct- Spill Box# Spill Box# <br /> Grade level Grade level <br /> Bucket Installation Type: CDirect Bury r* Direct Bury r Direct Bury r Direct Bury <br /> r Contained in Sump r Contained in Sump r Contained in Sump r Contained in Sump <br /> Bucket Diameter: 12.00 12.00 <br /> Bucket Depth: 12.00 12.00 <br /> Wait time between applying I min I min min min <br /> vacuum/water and start of test <br /> Test Start Time(Tl): 09:00:00 09:00:00 <br /> Initial Reading(Rl): 12.00 in. 11.75 in. <br /> Test End Time(TF): 10:00:00 10:00:00 <br /> Final Reading(RF): 12.00 in. 11.75 in. <br /> Test Duration(TF-T,): I min I min <br /> Change in Reading(RF-R,): 0.00 in. 0.00 in. <br /> Pass/Fail Threshold or Criteria: +/-0.25 +/-0.25 <br /> Pass Pass <br /> Comments-(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> took water off site for recycling <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCFING 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: 12/29/2015 <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:2324988 <br />