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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.FACILXI Y INFORMATION <br /> Facility Name:CHEVRON#208117 Date of Testing:2/6/2020 <br /> Facility Address:755 S.TRACY BLVD,TRACY,CA 95376 <br /> Facility Contact:Diane Province Phone:209-8300370 <br /> Date Local Agency Was Notified of Testing:2/5/2020 <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 I: F, CSLB Contractor � ICC Service Tech. Vs SWRCB Tank Tester r Other(Specify) <br /> License Number(s):74360 <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used By: P-1 Hydrostatic r Vacuum r7. Other <br /> Test Equipment Used:VACUUM TEST Equipment Resolution:0.1 aph <br /> Spill Box#Tank T 1 Spill Box#Tank T 2 <br /> Identify Spill Bucket(By Tank PREMIUM-Fill 1-Direct- REGULAR-Fill 1-Direct- Spill Box# Spill Box# <br /> Number,Stored Product,etc) Grade level in containment Grade level in containment <br /> sump sump <br /> C* Direct Bury (e Direct Bury (' Direct Bury r Direct Bury <br /> Bucket Installation Type: r Contained in Sump C' Contained in Sump (` Contained in Sump r Contained in Sump <br /> Bucket Diameter: 12.00 12.00 <br /> Bucket Depth: 14.00 14.00 <br /> Wait time between applying 15 min 15 min min min <br /> vacuum/water and start of test <br /> Test Start Time(Tl): 09:25:00 09:25:00 <br /> Initial Reading(Rl): 14.00 in. 14.00 in. <br /> Test End Time(TF): 10:25:00 10:25:00 <br /> Final Reading(RF): 14.00 in. 14.00 in. <br /> Test Duration(TF—Tl): 1 hr 1 hr <br /> Change in Reading(RF—Rl): 0.00 in. 0.00 in. <br /> Pass/Fail Threshold or Criteria: +/-4.00 +/-4.00 <br /> Test Result: Pass Pass 17 <br /> Comments-(include information on repairs made prior to testing, and recommended follow-up for faile to A <br /> Changed drain on 87 spill bucket.Restarted test buckets pass. �►� LO Zfl <br /> ENVIKH ALTH <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING TI HS 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: Date: 2/6/2020 <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:2344025 <br />