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KLULIVED <br /> FEB 2 2 2016 <br /> ENVIRON&ENTAL <br /> Spill Bucket Testing Report Form SW apNp� MENT <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: Chevron Date of Testing:01/25/16 <br /> Facility Address: 1960 W. 11 th 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)- Victoria McCartney <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name:Service Station Systems <br /> Technician Conducting Test: Marcos Mercado <br /> Credentials: Q CSLB Contractor Q ICC Service Tech. ❑SWRCB Tank Tester ❑ Other(Specify) <br /> License Number(s): License:485184 ICC:8049069-UT <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ❑X 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- Regu 03- Diesel <br /> ❑ <br /> Bucket Installation Type: Direct Bury r] Direct Bury E] Direct Bury ❑ Direct Bury <br /> ❑X Contained in Sump Q Contained in Sump Q Contained in Sump ❑ Contained in Sump <br /> Bucket Diameter. 12.00 in. 12.00 in. 12.00 in. <br /> Bucket Depth: 12.50 in. 12.50 in. 12.50 in. <br /> Wait time between applying 10 min. 10 min. 10 min. <br /> vacuum/water and start of test: <br /> Test Start Time(TI): 1:45pm 2:27pm 1:45pm <br /> Initial Reading(Ri ): 13.25 in. 11.56 in. 11.56 in. <br /> Test End Time(TF): 2:45pm 3:27pm 2:45pm <br /> Final Reading(PF): 13.25 in. 11.56 in. 11.56 in. <br /> Test Duration(TF-T 1): 1.00 hr. 1.00 hr. 1.00 hr. <br /> Change in Reading(RF-R,): 0.000 in. 0.000 in. 0.000 in. <br /> PasslFail Threshold or Criteria: ZERO LOSS ZERO LOSS ZERO LOSS <br /> Test Result: Q Pass ❑Fail ©Pass ❑Fail Q Pass ❑ Fail ❑ Pass ©Fail <br /> Comments: Failed initial test. Replaced O-ring and Drain Assembly on Diesel and Reg. Replaced O-ring on Prem <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> 1 hereby certify that all the information contained in this report is true,accurate,and In full compliance with legal requirements. <br /> . <br /> Technician's Signature. Date:01/25/16 <br /> 1 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 />