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i <br />SWRB, 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 completedr`m`a nQd `� <br />printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory ragency, <br />1. FACILITY INFORMATION <br />Facility Name: CHEVRON 208118 N4087-1-3 Date of Testing:2/13/2015 <br />Facility Address: 3355 E. HAMMER LANE @ HOLMAN RD, STOCKTON, CA 95212 <br />Facility Contact:MANAGER Phone: 209-477-3699 <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: David Mathie <br />Credentials): CSLB Contractor ICC Service Tech. rV, SWRCB Tank Tester r7 Other (Specify) <br />License Number(s):90-1429 <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used By: Hydrostatic rl Vacuum r Other <br />Test Eauinment Used: LAKE TEST I Equipment Resolution: 0.0625 in. 11 <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />Spill Box #Tank Tl I Spill Box #Tank T2 <br />SUPREME - Fill I - Direct - REGULAR - Fill I - Direct - Spill Box # Spill Box # <br />Grade level Grade level <br />II It"' Direct Bury Irr Direct Bury Ir <br />('' Direct Bury (� Direct BuryBucket Installation Type: r Contained in Sump Contained in Sump Contained in Sump f Contained in Sump <br />Bucket Diameter: <br />12.00 <br />12.00 <br />Bucket Depth: <br />14.00 <br />14.50 <br />Wait time between applying <br />vacuum/water and start of test <br />5 min <br />5 min <br />min <br />min <br />Test Start Time (Ti): <br />12:20:00 <br />12:20:00 <br />Initial Reading (Rl): <br />13.00 in. <br />13.50 in. <br />Test End Time(TF): <br />13:20:00 <br />13:20:00 <br />Final Reading (RF): <br />13.00 in. <br />13.50 in. <br />Test Duration(TF—TI): <br />1 hr <br />I hr <br />Change in Reading (RF—Rl) : <br />0.00 in. <br />0.00 in. <br />Pass/Fail Threshold or Criteria: <br />+/-0.00 <br />+/-0.00 <br />+/- <br />+/- <br />Comments - (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />CERTIFICATION OF TECI-INICIAN 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: 14 Date: 2/13/2015 <br />1State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more stringent. <br />WO: 2321579 <br />