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03/23/2015 5:48AM FAX 19252 71 Guadalupe Sanchez Q0010/0010 <br /> IF is <br /> SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intended for use by contractors performing annual testing of UST split containment structures. The completed form and <br /> printouts from tests(if applicable),should be provided to the facility awner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Wilson Way Chevron I Date of Tea_ting: _02/24/2015 <br /> Facility Address: 437 N. Wilson Way,Stockton,Ca.95205 — - <br /> Facility Contact: Aman Mehroke Phone: 209-942-2344 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(fpresent during testing): .Teff Wong <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Reliable Petroleum Services Inc. <br /> Technician Conducting Test: Guadalupe Sanchez <br /> Credentials': x CSLB Contractor x[CC Service Tech. 0 SWRCB Tank Tester ❑Other(Specify) <br /> License Number(s): 883706 5250451-UT <br /> 3. SPILL BUCKET TASTING INFORMATION <br /> Test Method Used: xHydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used: Standard.Tape Measure Equipment Resolution:N/A <br /> Identify Spill Bucket(By Tank 1 Tl:87 Fill 2 T2:91 All 3 T3• 4 T4: <br /> Number,Stored Product,etc. <br /> Bucket Installation Direct Bury Direct Bury Direct Bury Direct Bury <br /> x Contained in Sump x Contained in Sump ❑Contained,in Sumv I I Contained in Sum <br /> Bucket Diameter: 12" 12" <br /> Bucket Depth: 17%" 16%" <br /> Wait time between applying I minute 1 minute <br /> vacuum/water and start of test: <br /> Test Start Time(T,): 11:06 a.m. 11:06 a.m. <br /> Initial Reading(Rj): 13 W" 117/8" <br /> Test End Time(TF): 12:06 p.m. 12:06 p.m. <br /> Final Reading(RF): 13 Vs?v 11 7/8" <br /> Test Duration(TF—Tj): _ 1 hr i hr ~� <br /> Change in Reading(RF-Rl): 0 -----" 0 <br /> Pass/Fail Threshold or 1/16" 1/16„ <br /> Criteria: <br /> Test Result: x Pass ❑Fail x pass ❑IFail Pass ❑Fail Pass ❑Fail <br /> COlt Me11t8—(include information nn repairs made prior to testing, and recnrnmended follow-up fir failed test <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 02/24/2015 <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 />