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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 212470 Date of Testing:6/10/2020 <br /> Facility Address:3400 N MacArthur Drive,Tracy,CA 95376 <br /> Facility Contact:Diane Province Phone:209-8341220 <br /> Date Local Agency Was Notified of Testing:6/10/2020 <br /> Name of Local Agency Inspector(if present during testing): <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name:TANKNOLOGY INC. <br /> Technician Conducting Test:Brent Bowen <br /> Credentials): Pr' CSLB Contractor P– ICC Service Tech. W SWRCB Tank Tester r Other(Specify) <br /> License Number(s):74360 <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used By: r Hydrostatic W Vacuum r Other <br /> Test Equipment Used:VACUUM TEST Equipment Resolution:0.1 gph <br /> Spill Box#Tank Spill Box#Tank REG Spill Box#Tank Diesel- <br /> Identify Spill Bucket(By Tank PREMIUM-Fill I -Direct- UNLEAD-Fill I-Direct- Fill I-Direct-Grade level Spill Box# <br /> Number, Stored Product, etc) Grade level in containment Grade level in containment <br /> in containment sump <br /> sump sump <br /> l` Direct Bury r' Direct Bury r Direct Bury f Direct Bury <br /> Bucket Installation Type: f: Contained in Sump f: Contained in Sump to Contained in Sump f Contained in Sump <br /> Bucket Diameter: 12.00 12.00 12.00 <br /> Bucket Depth: 14.00 14.00 14.00 <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): 09:06:00 09:05:00 09:11:00 <br /> Initial Reading(RI): -30.00 in.H2O -30.00 in.H2O -30.00 in.H2O <br /> Test End Time(TF): 09:07:00 09:06:00 09:12:00 <br /> Final Reading(RF): -30.00 in.H2O -30.00 in.H2O -30.00 in.H2O <br /> Test Duration(TF-Tl): 1 min 1 min I min <br /> Change in Reading(RF-Rl): 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 /> 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 TECIINICIAN 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: *PY-e— Date: 6/10/2020 <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:2346554 <br />