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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#98264(N-534) Date of Testing:2/9/2016 <br /> Facility Address:3775 N.TRACY BLVD,TRACY,CA 95376 <br /> Facility Contact:MGR-PAT Phone:209-836-9422 <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:Todd Inderbitzen <br /> Credentials): r— CSLB Contractor P-1 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 P Vacuum r Other <br /> Test Equipment Used:VACUUM TEST Equipment Resolution:0.1 gph <br /> Spill Box#Tank T 1 Spill Box#Tank T3 <br /> Identify Spill Bucket(By Tank Spill Box#Tank T2 PLUS- <br /> Number, Stored Product, etc.) SUPREME-Fill 1-Direct- Fill 1-Direct-Grade level REGULAR-Fill 1-Direct- Spill Box# <br /> Grade level Grade level <br /> !' Direct Bury r Direct Bury r Direct Bury r Direct Bury <br /> Bucket Installation Type: G Contained in Sump C Contained in Sump to Contained in Sump C Contained in Sump <br /> Bucket Diameter: 11.00 11.00 11.00 <br /> Bucket Depth: 12.50 12.00 12.50 <br /> Wait time between applying <br /> 1 min 1 min 1 min min <br /> vacuum/water and start of test <br /> Test Start Time(Tl): 09:13:00 09:16:00 09:20:00 <br /> Initial Reading(Rl): 30.00 in.H2O 30.00 in.H2O 30.00 in.H2O <br /> Test End Time(TF): 09:14:00 09:17:00 09:21:00 <br /> Final Reading(RF): 30.00 in.H2O 30.00 in.H2O 30.00 in.H2O <br /> Test Duration(TF—TI): 1 min 1 min 1 min <br /> Change in Reading(RF—RI): 0.00 in.H2O 0.00 in.H2O 0.00 in.H2O <br /> Pass/Fail Threshold or Criteria: +/-4.00 +/-4.00 +/-4.00 +/- <br /> Tesi Lesult: Pass , Tass Pass <br /> Comments-(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> CERTIFICATION OF TECFINICIAN RESPONSIBLE FOR CONDUCTING TFUS 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: i Date: 2/9/2016 <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:2326366 <br />