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a <br /> SWRCB,January 2006 <br /> Spill Bucket Testi o r <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 Date of Testing:12/13/12 <br /> Facility Address: 6633 Pacific Ave Stockton, CA 95207-3719 <br /> Facility contact: Manager (209)477-4294 <br /> Date Local Agency Was Notified of Testing: / / <br /> Name of Local Agency Inspector (if present during testing): Garrett Backus <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name:Service Station Systems <br /> Technician Conducting Test:M ke Briggs <br /> Credentialsi: ®CSLB Contractor Q ECC Service Tech. ❑ SWRCB Tank Tester ❑ Other(Specify) <br /> License Number(s): License:485184 ICC:8033115-UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ® Hydrostatic ❑vacuum ❑ Other <br /> Test Equipment Used: Measuring Tape Equipment Resolution:1/16 in. <br /> Identify Spill Bucket (By rank 1 Fill Bucket 2 Fill Bucket 3 Fill Bucket 4 <br /> Number,Stored Product,etc.) 01 Prem 02 Re u 03 Re u <br /> Bucket installation Type: Direct Bury ❑ Direct Bury Direct Bury E] Direct Bury <br /> Contained in Sump ®Contained In Sump Contained in Sump ❑ Contained in Sump <br /> Bucket Diameter: 12.00 in. <br /> Bucket Depth: 16.00 in. <br /> Wait time between applying <br /> vacuum/water and start of test: 5 min. <br /> Test Start Time(Ti): 11:00am " <br /> Initial Reading(R ): 14.250 in. <br /> Test End Time(TF): 12:00pm <br /> Final Reading(Pf): 14.250 in. <br /> Test Duration(TF-T 1): 1.00 hr. <br /> Change in Reading(RF-R,): 0.0000 in. <br /> Pass/Fail Threshold or Criteria: ZERO LOSS <br /> Test Result: j pass ❑Fait <br /> Comments: Test performed for Permit Final due to installation of bucket sleeves on 87-1. Y <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the information contained in this report Is Prue,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: A/ <br /> Date: 12/13/12 <br /> 1 State laws and regulations do not currently require tbstirig to be performed by a qualified contractor.However,local requirements <br /> may be more stringent. <br />