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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 structures. The completed form and <br /> printouts from tests (if applicable), should be provided to the facility or-vner/operator for submittal to the local regulatory agency. <br /> 1 . FACILITY INFORMATION <br /> Facility Name: CHEVRON #208117 Date of Testing: 2/7/2019 <br /> Facility Address: 755 S. TRACY BLVD , TRACY, CA 95376 <br /> Facility Contact: MGR - MARIA Phone : 209-830-0370 _ <br /> Date Local Agency Was Notified of Testing: 2/4/2019 _ <br /> Name of Local Agency Inspector (if present during testing): ZUNA <br /> 2 . TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY INC. <br /> Technician Conducting Test: Jesus Saldivar <br /> Credentialsi : CSLB Contractor W ICC Service Tech. r' SWRCB Tank Tester Other (Specify) <br /> License Number(s) : <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used By : Hydrostatic 17 Vacuum Other <br /> Test Equipment Used : LAKE TEST Equipment Resolution : 0.0625 in. <br /> Spill Box # Tank T 2 Spill Box # Tank T 1 <br /> Identify Spill Bucket (By Tank REGULAR - Fill I - Direct - PREMIUM - Fill 1 - Direct - Spill Box # Spill Box # <br /> Number, Stored Product, etc.) Grade level in containment Grade level in containment <br /> sump sump <br /> (` Direct Bury C' Direct Bury r Direct Bury f Direct Bury <br /> Bucket Installation Type : (: Contained in Sump C+ Contained in Sump r Contained in Sump Contained in Sump <br /> Bucket Diameter: 14.00 14.00 <br /> Bucket Depth : 15.00 15.00 <br /> Wait time between applying <br /> 5 min 5 min min min <br /> vacuum/water and start of test <br /> Test Start Time (TI): 10:00:00 10:00:00 <br /> Initial Reading (RI): 15.00 his H2O 15.00 in. H2O <br /> Test End Time(TF): 11 :00:00 11 :00:00 <br /> Final Reading (RF): 15.00 in. H2O 15.00 in. H2O <br /> Test Duration(TF—TI): 1 hr 1 his <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 /> COMMeUtS not (include information on repairs made prior to testing, and recommended folloiv- 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 hwe, accurate, and in full compliance with legal requirements. <br /> Technician's Signature : Ae&z Date : 2/7/2019 <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 : 2339338 <br />