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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#208117 Date of Testing:2/16/2022 <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:2/9/2022 <br /> Name of Local Agency Inspector(if present during testing):Unknown <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:TANKNOLOGY INC. <br /> Technician Conducting Test:Jesus Saldivar <br /> Credentials l: r CSLB Contractor rv— ICC Service Tech. r SWRCB Tank Tester r Other(Specify) <br /> Licensc Number(s): <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used By: Hydrostatic W Vacuum F Other <br /> Test Equipment Used:VACUUM TEST Equipment Resolution:0.1 gph <br /> Spill Box#Tank T 2 Spill Box#Tank T 1 <br /> Identify Spill Bucket(By Tank REGULAR-Fill 1-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 /> rDirect Bury C Direct Bury r Direct Bury C Direct Bury <br /> Bucket Installation Type: (: Contained in Sump C Contained in Sump r Contained in Sump C Contained in Sump <br /> Bucket Diameter: 12.00 12.00 <br /> Bucket Depth: 15.00 15.00 <br /> Wait time between applying <br /> 1 min 1 min min min <br /> vacuum/water and start of test <br /> Test Start Time(TI): 08:55:00 08:57:00 <br /> Initial Reading(RI): 30.00 in.1420 30.00 in.H2O <br /> Test End Time(TF): 08:56:00 08:58:00 <br /> Final Reading(RF): 28.00 in.H2O 28.00 in.H2O <br /> Test Duration(TF—TI): 1 min 1 min <br /> Change in Reading(RF—RI): -2.00 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 TECHNICIAN 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: Al 4L Date: 2/16/2022 <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:2353595 <br />