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91 0 <br /> SWRCB,January 2006 <br /> Spill c Testi For <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 facifity owner/operator for submittal to the local regulatory agency. <br /> 1.FACILITY INFORMATION <br /> Facility Name: Chevron Date of Testing:12/9/13 <br /> Facility Address: 1960 W. 11th St Tracy, CA 95376-3738 <br /> Facility Contact: Helen McCarty (209)836-3181 <br /> Date Local Agency Was Notified of Testing: / / <br /> Name of Local Agency Inspector (if present during testing): Thuy Tran <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name:Service Station Systems <br /> Technician Conducting Test: Kris Bell <br /> Credentials': Q CSLB Contractor Q ICC Service Tech. ❑SWRCB Tank Tester ❑ Other(Specify) <br /> License Number(s): License:485184 ICC:5297793-UT <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: Q Hydrostatic ❑vacuum ❑ Other <br /> Test Equipment Used: Measuring Tape Equipment Resolution:1/16 in. <br /> Identify Spill Bucket (By Tank 1 Fill Bucket 2 Fill Bucket 3 Fill Bucket 4 <br /> Number,Stored Product,etc.) 01 Prem 02 Plus 03 Re u <br /> Bucket Installation Type: ❑Direct Bury ❑Direct Bury <br /> Q Contained in Sump ❑Contained in Sump <br /> Bucket Diameter: 13.00 in. <br /> I.Lucket Depth: 12.50 in. <br /> Wait time between applying <br /> vacuum/water and start of test: 5 min. <br /> Test Start Time(TI): 2:00pm <br /> Initial Reading(Ri ): 11.750 in. <br /> Test End Time(TF): 3:00pm <br /> Final Reading(RF): 11.750 in. <br /> Test Duration(TF-T ): 1.00 hr. <br /> Change in Reading(RF-R!): 0.0000 in. <br /> Pass/Fail Threshold or Criteria: ZERO LOSS <br /> �'1`@-t3t Re�tiflt , <br /> ®Pass ❑Fait ❑Pass' Q.Fad <br /> Comments:Bucket Test performed for Permit Final due to replacement of 87 Fill Bucket on 11/22113. <br /> Replaced 87 Fill Cap-Re-tested&Passed. <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/a full compliance with legal requirements. <br /> Technician's Signature: ' ' Date:12/9/13 <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 />