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SWRCB, January 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intended for use by contractors per forming annual testing of UST spill containment structzu•es. The completed form and <br /> printouts fr•oin 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 209167 Date of Testing : 2/7/2020 <br /> Facility Address : 1234 E. YOSEMITE AVE @ SPRECKLES, MANTECA, CA 95336 <br /> Facility Contact: Diane Province Phone: 209-8247433 <br /> Date Local Agency Was Notified of Testing: 1 /31 /2020 — --- --- <br /> Name of Local Agency Inspector (if present during testing): PAULNSO <br /> 2 . TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY INC. 11015 gig -al I gig 06 - <br /> Technician Conducting Test: Jesus Saldivar -- - <br /> - - - <br /> Credentialsi : r; CSLB Contractor r ICC Service Tech. r SWRCB Tank Tester Other (Specify) <br /> License Number(s) : <br /> 3 . SPILL BUCKET TESTING INFORMATION <br /> E <br /> [[Bke <br /> ethod Used By : Hydrostatic W Vacuum Other <br /> quipment Used: VACUUM TEST Equipment Resolution : 0. 1 gph <br /> Spill Box # Tank T:2 Spill Box # Tank T: 1 <br /> Spill Bucket (By Tank REGULAR - Fill 1 - Direct - SUPREME - Fill 1 - Direct - Spill Box # Spill Box # <br /> r, Stored Product, etc.) Grade level Grade level <br /> i <br /> f� Direct Bury (�' Direct Bury (` Direct Bury C` Direct Bury <br /> Installation Type : (` Contained in Sump ( ' Contained in Sump r Contained in Sump (` Contained in Sump <br /> Diameter: 12.00 12.00 <br /> Depth: 14.00 13 .00 <br /> me between applying I ruin 1 min min min <br /> vacuum/water and start of test <br /> Test Start Time (Tl): 09:00:00 09:02:00 <br /> Initial Reading (Rt): 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 30.00 in. H2O <br /> Test Duration(TF-TI): 1 min 1 min <br /> Change in Reading (RF-RI) : 0.00 in. H2O 0.00 in. H2O <br /> Pass/Fail Threshold or Criteria: +/- 0.00 +/- 0.00 +/- +/- <br /> Test Result: Pass Pass <br /> Comments (include information on repairs made prior to testing, and recommended follow- zip for failed tests) <br /> CERTIFICATION OF TEC> INICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the inforrrzation contained in this report is true, accurate, and in full compliance with legal requirements. <br /> Technician's Signature : 1AW e /. Date: 2/7/2020 <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 : 2344027 <br />