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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 208118 N-4087-1-3 Date of Testing: 1/16/2020 <br /> Facility Address:3355 E.HANEvIER LANE @ HOLMAN RD,STOCKTON,CA 95212 <br /> Facility Contact:MANAGER Phone:209-477-3699 <br /> Date Local Agency Was Notified of Testing: 1/2/2020 <br /> Name of Local Agency Inspector(if present during testing):UNKNOWN <br /> x <br /> 2.TESTING CONTRACTOR INFORMATION <br /> I E <br /> Company Name:TANKNOLOGY INC. <br /> Technician Conducting Test:Jesus Saldivar JAW 2 1 7020 <br /> Credentials): r— CSLB Contractor W1 ICC Service Tech. r SWRCB Tank Tester r Other(Specify) <br /> License Number(s): phowantsihAQ11AI HEALTH <br /> 3.SPILL BUCKET TESTING INFORMATION DEPARTMENT <br /> Test Method Used By: r-1 Hydrostatic V Vacuum r Other <br /> Test Equipment Used:VACUUM TEST Equipment Resolution:0.1 gph <br /> Identify Spill Bucket(By Tank Spill Box#Tank T2 Spill Box#Tank T1 <br /> Number,Stored Product, etc) G'U'AR-FillI-Direct- SUPREME-FillI-Direct- Spill Box Spill Box# <br /> Grade level Grade level <br /> r Direct Bury f•' Direct Bury r Direct Bury r Direct Bury <br /> Bucket Installation Type: (` Contained in Sump r Contained in Sump f 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 <br /> vacuum/water and start of test 1 min 1 min min min <br /> Test Start Time(Tl): 09:00:00 09:02:00 <br /> Initial Reading(RI): 30.00 in.H2O 30.00 in.H2O <br /> Test End Time(TF): 09:01:00 09:03:00 <br /> Final Reading(RF): 30.00 in.H2O 28.00 in.H2O <br /> Test Duration(TF—TI): 1 min I min <br /> Change in Reading(RF—RI): 0.00 in.H2O -2.00 in.H2O <br /> Pass/Fail Threshold or Criteria: +/-4.00 +/-4.00 +/- <br /> Test Result: Pass Pass <br /> Comments-(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> CERTIFICATION OF TECHMCIAN RESPONSIBLE FOR CONDUCTING THIS 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: 1-41: Date: 1/16/2020 <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:2343357 <br />