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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 209167 Date of Testing:2/12/2015 <br /> Facility Address: 1234 E.YOSEMITE AVE @ SPRECKLES,MANTECA,CA 95336 <br /> Facility Contact:MANAGER-KIM Phone:209-824-7433 <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 /> Credentialsi: WA CSLB Contractor r ICC Service Tech. M SWRCB Tank Tester MA Other(Specify) <br /> License Number(s):743160 <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used By: M Hydrostatic W Vacuum MA Other <br /> Test Equipment Used:VACUUM TEST Equipment Resolution:0.1 gph <br /> i ng <br /> MON' .., �N , m � <br /> Identify Spill Bucket(By Tank Spill Box#Tank T:I Spill Box#Tank T:2 <br /> Number, Stored Product, etc.) SUPREME-Fill 1-Direct- REGULAR-Fill l-Direct- Spill Box# Spill Box# <br /> Grade level Grade level <br /> Direct Bury Direct Bury Direct Bury Direct Bury <br /> Bucket Installation Type: Contained in Sump 0 Contained in Sump II Contained in Sump r Contained in Sump <br /> Bucket Diameter: 12.00 12.00 <br /> Bucket Depth: 12.50 12.50 <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(RI): 30.00 in.H2O 30.00 in.H2O <br /> Test End Time(TF): 09:16:00 09:19:00 <br /> Final Reading(RF): 27.00 in.H2O 26.00 in.H2O <br /> Test Duration(TF—TI): I min 1 min <br /> Change in Reading(RF—RI): -3.00 in.H2O -4.00 in.H2O <br /> Pass/Fail Threshold or Criteria: +/-4.00 +/-4.00 +/- <br /> Comments-(include information on repairs made prior to testing, and recommended follow-up for faiMl <br /> Q; <br /> a <br /> 99 1 <br /> -:a <br /> .mom e— <br /> CERTIFICATION OF TECEMCIAN RESPONSIBLE FOR CONDUCTING THLS 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: } ,Wl— Date: 2/12/2015 <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:2321576 <br />