Laserfiche WebLink
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 372736 Date of Testing:2/3/2022 <br /> Facility Address:9484 West Lane,Stockton,CA 95210 <br /> Facility Contact:Diane Province Phone:209-4749825 <br /> Date Local Agency Was Notified of Testing: 1/27/2022 <br /> Name of Local Agency Inspector(if present during testing):Vicky <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:TANKNOLOGY INC. <br /> Technician Conducting Test:Jesus Saldivar <br /> Credentials l: r CSLB Contractor ICC Service Tech. r SWRCB Tank Tester r Other(Specify) <br /> License 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 /> I JL <br /> Spill Box#Tank Tl Spill Box#Tank T2 Spill Box#Tank T3:diesel <br /> Identify Spill Bucket(By Tank SUPREME-Fill I-Direct- REGULAR-Fill l-Direct- Diesel-Fill 1-Direct- Spill Box# <br /> Number, Stored Product, etc) Below Grade in Below Grade in Below Grade in <br /> containment sump containment sump containment sump <br /> Bucket Installation Type: rDirect Bury C Direct Bury r Direct Bury C Direct Bury <br /> C: Contained in Sump C Contained in Sump C: Contained in Sump C Contained in Sump <br /> Bucket Diameter: 12.00 12.00 12.00 <br /> Bucket Depth: 16.00 16.00 16.00 <br /> Wait time between applying 1 min 1 min 1 min min <br /> vacuum/water and start of test <br /> Test Start Time(TI): 09:00:00 09:02:00 09:04:00 <br /> Initial Reading(RI): 30.00 in.1420 30.00 in.H2O 30.00 in.1420 <br /> Test End Time(TF): 09:01:00 09:03:00 09:05:00 <br /> Final Reading(RF): 28.00 in.H2O 28.00 in.H2O 28.00 in.H2O <br /> Test Duration(TF—TI): 1 min 1 min 1 min <br /> Change in Reading(RF—RI): -2.00 in.H2O -2.00 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 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: 2/3/2022 <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:2353602 <br />