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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 1 Date of Testing:2/1/2018 <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:2/26/2018 <br /> Name of Local Agency Inspector(if present during testing):ZURA <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name:TANKNOLOGY INC. <br /> Technician Conducting Test:Jesus Saldivar <br /> Credentialsl: r CSLB Contractor FF ICC Service Tech. r SWRCB Tank Tester r Other(Specify) <br /> License Number(s): <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used By: r Hydrostatic r Vacuum r Other <br /> Test Equipment Used:LAKE TEST Equipment Resolution:0.0625 in. <br /> Identify Spill Bucket(By Tank Spill Box#Tank T:2 Spill Box#Tank T:1 <br /> Number, Stored Product, etc.) REGULAR-Fill I -Direct- SUPREME-Fill 1-Direct- Spill Box# Spill Box# <br /> Grade level Grade level <br /> r* Direct Bury Direct Bury f 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: 12.00 12.00 <br /> Bucket Depth: 14.00 14.00 <br /> Wait time between applying <br /> 5 min 5 min min min <br /> vacuum/water and start of test <br /> Test Start Time(Tl): 09:00:00 09:00:00 <br /> Initial Reading(Rl): 14.00 in.H2O 14.00 in.H2O <br /> Test End Time(TF): 10:00:00 10:00:00 <br /> Final Reading(RF): 14.00 in.H2O 14.00 in.H2O <br /> Test Duration(TF—Tl): 1 hr 1 hr <br /> Change in Reading(RF—RI): 0.00 in.H2O 0.00 in.H2O <br /> Pass/Fail Threshold or Criteria: +/-0.00 +/-0.00 +/- +/- <br /> �^���II�� <br /> Comments-(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> CERTIFICATION OF TECIINICIAN RESPONSIBLE FOR CONDUCTING TMS 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: '4"61 -- Date: 2/1/2018 <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:2334340 <br />