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E <br />Spill Bucket Testing Report Form <br />SWRCB, January 2006 <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 #208117 <br />Date of Testing: 2/2/2018 <br />Facility Address: 755 S. TRACY BLVD, TRACY, CA 95376 <br />Facility Contact: MGR - MARIA Phone: 209-830-0370 <br />Date Local Agency Was Notified of Testing: 1/16/2018 <br />Name of Local Agency Inspector (if present during testing): andrea <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: TANKNOLOGY INC. <br />Technician Conducting Test: Tim Elebeck <br />Credentials]: r CSLB Contractor 170 ICC Service Tech. r— SWRCB Tank Tester r Other (Specify) <br />License Number(s): 8001435 <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used By: Hydrostatic Vacuum Other <br />Test Equipment Used: LAKE TEST Equipment Resolution: <br />0.0625 in. <br />Spill Box # Tank T 1 <br />Spill Box # Tank T 2 <br />Identify Spill Bucket (By Tank <br />PREMIUM - Fill 1 - Direct - <br />REGULAR - Fill 1 - Direct - <br />Spill Box # <br />Spill Box # <br />Number, Stored Product, etc.) <br />Grade level in containment <br />Grade level in containment <br />sump <br />sump <br />Direct Bury <br />r Direct Bury <br />r Direct Bury <br />Direct Bury <br />Bucket Installation Type: <br />G Contained in Sump <br />Oi Contained in Sump <br />r Contained in Sump <br />r Contained in Sump <br />Bucket Diameter: <br />12.00 <br />12.00 <br />Bucket Depth: <br />12.00 <br />12.00 <br />Wait time between applying <br />vacuum/water and start of test <br />5 min <br />5 min <br />min <br />min <br />Test Start Time (Tl): <br />12:30:00 <br />09:30:00 <br />Initial Reading (Rt): <br />11.50 in. H2O <br />11.50 in. H2O <br />Test End Time(TF): <br />01:30:00 <br />10:30:00 <br />Final Reading (RF): <br />11.50 in. H2O <br />11.50 in. H2O <br />Test Duration(TF—T,): <br />1 hr <br />1 hr <br />Change in Reading (RF—RI) : <br />0.00 in. H2O <br />0.00 in. H2O <br />Pass/Fail Threshold or Criteria: <br />+/-0.00 <br />+/-0.00 <br />Ca'-..'*:�`�', vM. <br />'NO .;. iSt 4.3?r. <br />`v"'-. hr, 4iri-.+.. :r/,}.i:..-. f�/ •.. ..3:: / <br />f/f�%� /� a/.Y?Y>.�:1<.,�.,,...;,. <br />Comments - (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />replaced 91 drain valve it was leaking test and passed <br />CERTIFICATION OF TECIINICIAN RESPONSIBLE FOR CONDUCTING TICS 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 <br />��p f.laa.ulC <br />Date: 2/2/2018 <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: 2334338 <br />