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C! <br />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 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 208118 N4087-1-3 Date of Testing: 2/6/2017 <br />Facility Address: 3355 E. HAMMER LANE @ HOLMAN RD, STOCKTON, CA 95212 <br />Facility Contact: MANAGER Phone: 209477-3699 <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: Jesus Saldivar <br />Credentialsl : r—, CSLB Contractor F7 ICC Service Tech. r7, SWRCB Tank Tester r—, Other (specENVI RON MENTAL HEALTH <br />License Number(s): DEPARTMENT <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used By: Hydrostatic Vacuum Other <br />Test Equipment Used: Equipment Resolution: <br />Identify Spill Bucket (By Tank Spill Box # Tank T1 Spill Box # Tank T2 <br />Number, Stored Product, etc.) SUPREME - Fill 1 -Direct - REGULAR -Fill 1 -Direct - Spill Box # Spill Box # <br />Grade level Grade level <br />Bucket Installation Type: <br />Direct Bury <br />r Contained in Sump <br />Direct Bury <br />r Contained in Sump <br />r Direct Bury <br />f'' Contained in Sump <br />r Direct Bury <br />r Contained in Sump <br />Bucket Diameter: <br />12.00 <br />12.00 <br />Bucket Depth: <br />14.00 <br />14.00 <br />Wait time between applying <br />vacuum/water and start of test <br />1 min <br />1 min <br />min <br />min <br />Test Start Time (TI): <br />08:00:00 <br />10:11:00 <br />Initial Reading (RI): <br />30.00 in. HG <br />30.00 in. HG <br />Test End Time(TF): <br />08:01:00 <br />10:12:00 <br />Final Reading (RF): <br />28.00 in. HG <br />30.00 in. HG <br />Test Duration(TF—TI): <br />1 min <br />1 min <br />Change in Reading (RF—RI) : <br />-2.00 in. HG <br />0.00 in. HG <br />Pass/Fail Threshold or Criteria: <br />+/-4.00 <br />+/-4.00 <br />+/- <br />+/- <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: 2/6/2017 <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: 2329828 <br />