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SWRCB, January 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intended for use by contractors per forming annual testing of UST spill containment structures. The completed form and <br /> printouts from tests (if applicable) , should be provided to the facility orwner/operator for submittal to the local regulatory agency. <br /> 1 . FACILITY INFORMATION <br /> Facility Name: CHEVRON # 94275 Date of Testing: 2/20/2020 <br /> Facility Address : 2905 W. BENJAMIN HOLT @ I-5, STOCKTON, CA 95207 <br /> Facility Contact: Diane Province Phone: 209-4785555 <br /> Date Local Agency Was Notified of Testing : 2/ 13/2020 <br /> Name of Local Agency Inspector (if present during testing): PAUL <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY INC. <br /> Technician Conducting Test: Jesus Saldivar -1alago - <br /> Credentials1 : CSLB Contractor W, ICC Service Tech. r SWRCB Tank Tester re Other (Specify) <br /> License Number(s) : <br /> 3 . SPILL BUCKET TESTING INFORMATION <br /> Test Method Used By : Hydrostatic Vacuum Other <br /> Test Equipment Used : VACUUM TEST Equipment Resolution: 0. 1 gph <br /> Spill Box # Tank T2 REG Spill Box # Tank T 1 Spill Box # Tank T3 <br /> Identify Spill Bucket (By Tank UNLEAD - Fill 1 - Direct - SUPREME - Fill 1 - Direct - DIESEL2 - Fill 1 - Direct - Spill Box # <br /> Number, Stored Product, etc.) Grade level in containment Grade level in containment Grade level in containment <br /> sump sump sump <br /> (" Direct Bury ( Direct Bury (' Direct Bury ( ` Direct Bury <br /> Bucket Installation Type : G Contained in Sump C: Contained in Sump [o Contained in Sump f Contained in Sump <br /> Bucket Diameter: 12.00 12.00 12.00 <br /> Bucket Depth : 13.00 13 .00 13 .00 <br /> Wait time between applying I min 1 min 1 min min <br /> vacuum/water and start of test <br /> Test Start Time (TI): 08 :00:00 08:02:00 08 :04:00 <br /> Initial Reading (RI): 30.00 in. H2O 30.00 in. H2O 30.00 in. H2O <br /> Test End Time(TF): 08:01 :00 08:03 :00 08:05 :00 <br /> Final Reading (RF): 30.00 in. H2O 28.00 in. H2O 30.00 in. H2O <br /> Test Duration(TF—TI): 1 min 1 min 1 min <br /> Change in Reading (Rg—RI) : 0.00 in. H2O -2.00 in. H2O 0.00 in. H2O <br /> Pass/Fail Threshold or Criteria: +/- 4.00 +/- 4. 00 +/- 4.00 +/- <br /> Test Result: Pass 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 : dL d« Date : 2/20/2020 <br /> 1 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 : 2344038 <br />