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SWRCB,January 2006 <br /> Spill Bucket Testing Report Form .a. <br /> This form is intended for use by contractors performing annual testing of UST spill containment structures. The completed fprl <br /> printouts from tests(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory age-' <br /> 1.FACILITY INFORMATION <br /> Facility Name:CHEVRON#201383(N-2515-1-1) Date of Testing:2/6/2015 <br /> Facility Address: 1960 W. 11TH STREET @ CORRAL HOLLOW,TRACY,CA 95376 <br /> Facility Contact:MGR-HELEN Phone:209-836-3181 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name:TANKNOLOGY INC. <br /> Technician Conducting Test:Gilbert Garcia <br /> Credentials: W' CSLB Contractor ICC Service Tech. r SWRCB Tank Tester Other(Specify) <br /> License Nttmber(s):743160 <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used By: Hydrostatic �' Vacuum Other <br /> Test Equipment Used:VACUUM TEST Equipment Resolution:0.1 gph <br /> Spill Box#Tank TlSpill Box#Tank T3 <br /> Spill Box#Tank T2 PLUS- <br /> Identify Spill Bucket(By Tank SUPREME-Fill 1-Direct- REGULAR-Fill 1 -Direct- <br /> Fill 1 -Direct-Grade level Spill Box# <br /> Number, Stored Product, etc.) Grade level in containment in containment sump Grade level in containment <br /> sump sump <br /> f Direct Bury r Direct Bury r Direct Bury f Direct Bury <br /> Bucket Installation Type: (* Contained in Sump 0 Contained in Sump t+ Contained in Sump r Contained in Sump <br /> Bucket Diameter: 12.00 12.00 12.00 <br /> Bucket Depth: 12.50 12.50 12.50 <br /> Wait time between applying 1 min 1 min 1 min min <br /> vacuum/water and start of test <br /> Test Start Time(Tl): 09:26:00 09:20:00 09:17:00 <br /> Initial Reading(RI): 30.00 in.H2O 30.00 in.H2O 30.00 in.H2O <br /> Test End Time(TF): 09:27:00 09:21:00 09:18:00 <br /> Final Reading(RF): 30.00 in.H2O 29.00 in.H2O 27.00 in.H2O <br /> Test Duration(TF—TI): 1 min 1 min 1 hr <br /> Change in Reading(RF—RI): 0.00 in.H2O -1.00 in.H2O -3.00 in.H2O <br /> Pass/Fail Threshold or Criteria: +/-4.00 +/-4.00 +/-4.00 +/- <br /> ' �Result' <br /> Fads : <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: 2/6/2015 <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:2321577 <br />