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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 cornpletedform 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 307709 Date of Testing : 3/ 13/2020 <br /> Facility Address: 10858 TRINITY PKWY , STOCKTON, CA 95219 <br /> Facility Contact: Diane Province Phone: 209-9522213 <br /> Date Local Agency Was Notified of Testing: 3/6/2020 <br /> Name of Local Agency Inspector (ifpresent during testing): PAUL <br /> 2 . TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY INC. <br /> Technician Conducting Test: Jesus Saldivar <br /> - <br /> Credentials ) : rz CSLB Contractor W'' ICC Service Tech. SWRCB Tank Tester r` Other (Specify) <br /> License Number(s) : <br /> 3 . SPILL BUCKET TESTING INFORMATION <br /> Test Method Used By : Hydrostatic W, Vacuum Other <br /> Test Equipment Used : VACUUM TEST Equipment Resolution : 0. 1 gph <br /> Spill Box # Tank T1 Spill Box # Tank T-2 Spill Box # Tank T-3 Diesel <br /> Identify Spill Bucket (By Tank UNLEADED - Fill 1 - Direct PREMIUM - Fill 1 - Direct - _ Fill 1 - Direct - Grade level Spill Box # <br /> Number, Stored Product, etc.) - Grade level in Grade level in containment ll containment sump <br /> containment sump sump <br /> Direct Bury r Direct Bury r Direct Bury r Direct Bury <br /> Bucket Installation Type : (; Contained in Sump (7 Contained in Sump (* Contained in Sump Contained in Sump <br /> Bucket Diameter: 12.00 12.00 12.00 <br /> Bucket Depth: 15.00 15 .00 15.00 <br /> Wait time between applying I min 1 min I min min <br /> vacuum/water and start of test <br /> Test Start Time (TI): 08:00:00 08 :02:00 08 :04:00 <br /> Initial Reading (RI ): 30.00 in. H2O 30.00 in. H2O 30.00 in. H2O <br /> Test End Time(Tg): 08:01 :00 08:03 :00 08:05 :00 <br /> Final Reading (RF): 30.00 in. 1120 29.00 in. H2O 28.00 in. H2O <br /> Test Duration(TF—TI): 1 min I min 1 min <br /> Change in Reading (Rg—RI ) : 0.00 in. H2O 4 .00 in. H2O -2.00 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 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 : / ew4 Date: 3/ 13/2020 <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: 2344224 <br />