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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 com t or a <br /> printouts from tests(if applicable),should be provided to the facility owner/operator for submittal to the local regulatory agea IVED <br /> 1.FACILITY INFORMATION JAN 2 9 2015 <br /> Facility Name:CHEVRON 201761 1 Date of Testing:l/I <br /> Facility Address: 1103 S.MAIN ST.PERMIT NUMB.N-3315,MANTECA,CA 95337 — <br /> Facility Contact:MGR-MARIE Phone:209-825-0174 <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): P— CSLB Contractor FF ICC Service Tech. r— SWRCB Tank Tester r— Other(Specify) <br /> License Number(s):743160 <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used By: r7 Hydrostatic rv—o-' Vacuum Other <br /> Test Equipment Used:VACUUM TEST Equipment Resolution:0.1 gph <br /> ., <br /> 7777 <br /> Spill Box#Tank Tl Spill Box#Tank T2 Regular Spill Box#Tank T3 Regular <br /> Identify Spill Bucket(By Tank Supreme SUPREME-Fill 1 2 REGULAR-Fill 1 -Direct 1 REGULAR-Fill 1 -Direct Spill Box# <br /> Number,Stored Product, etc.) -Direct-Grade level in -Grade level in -Grade level in <br /> containment sump containment sump containment sump <br /> Direct Bury i Direct Bury r Direct Bury r Direct Bury <br /> Bucket Installation Type: l* Contained in Sump f•" Contained in Sump r Contained in Sump C 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 <br /> 1 min 1 min 1 min min <br /> vacuum/water and start of test <br /> Test Start Time(TI): 09:10:00 09:14:00 09:17:00 <br /> Initial Reading(Rl): 30.00 in.H2O 30.00 in.H2O 30.00 in.H2O <br /> Test End Time(TF): 09:11:00 09:15:00 09:18:00 <br /> Final Reading(RF): 27.00 in.H2O 30.00 in.H2O 30.00 in.H2O <br /> Test Duration(TF—TI): I min 1 min I min <br /> Change in Reading(RF—RI): -3.00 in.H2O 0.00 in.H2O 0.00 in.H2O <br /> Pass/Fail Threshold or Criteria: +/-4.00 +/-4.00 +/-4.00 +/- <br /> Test <br /> Comments-(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> CERTIFICATION OF TECHMCIAN RESPONSIBLE FOR CONDUCTING TMS 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: 1/12/2015 <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:2320965 <br />