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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 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 N-4087-1-3 I Date of Testing: 1/17/2018 <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: 1/17/2018 <br /> Name of Local Agency Inspector(if present during testing): <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name:TANKNOLOGY INC. <br /> Technician Conducting Test:Brent Bowen <br /> Credentials): P7 CSLB Contractor W ICC Service Tech. rv-1, SWRCB Tank Tester r—, Other(Specify) <br /> License Number(s):743160 <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used By: Hydrostatic W Vacuum Other <br /> Test Equipment Used:VACUUM TEST Equipment Resolution:0.1 gph <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 /> Direct Bury C« Direct Bury r Direct Bury r Direct Bury <br /> Bucket Installation Type: r Contained in Sump r Contained in Sump r Contained in Sump r Contained in Sump <br /> Bucket Diameter: 13.00 13.00 <br /> Bucket Depth: 14.00 14.00 <br /> Wait time between applying <br /> 1 min 1 min min min <br /> vacuum/water and start of test <br /> Test Start Time(Tl): 09:15:00 09:18:00 <br /> Initial Reading(Rt): -30.00 in.H2O -30.00 in.1420 <br /> Test End Time(TF): 09:16:00 09:19:00 <br /> Final Reading(RF): -30.00 in.H2O -30.00 in.H2O <br /> Test Duration(TF-TI): 1 min 1 min <br /> Change in Reading(RF-Rl): 0.00 in.H2O 0.00 in.H2O <br /> Pass/Fail Threshold or Criteria: +/-4.00 +/-4.00 +/- <br /> Test Result: Pass Pass <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: 1/17/2018 <br /> IState laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements may be more stringent. <br /> WO:2334339 <br />