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SWRCB, January 2006 <br />9. S@11 Bucket Testing RepoiWorm <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 91452 (N-618) <br />DateofTesting: 01/08/2008 <br />Facility Address: 334 E. MAIN ST @ HWY 99, RIPON, CA, 95366 <br />Facility Contact: DEALER - MOHINDER <br />Phone: (209) 599-2313 <br />Date Local Agency Was Notified of Testing: / / <br />Name of Local Agency Inspector (if present during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: TANKNOLOGY, INC. <br />Technician Conducting Test: HEATH MCEVER <br />Credentialst: <br />❑ <br />CSLB Contractor [�] <br />ICC Service Tech. <br />❑ <br />SWRCB Tank Tester <br />E <br />Other (Specify) SERVICE TECH <br />License Number: 5236756 -UT <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: <br />Hydrostatic Vacuum ❑ Other <br />Test Equipment Used: WATER <br />Equipment Resolution: INCHES <br />Identify Spill Bucket(By Tank <br />Number, Stored Product, etc) <br />t 1 SUP FILL <br />Z 2 PLU FILL <br />3 3 UNL FILL <br />4 <br />Bucket Installation Type: <br />❑ Direct Bury <br />Contained in Sumpx❑ <br />❑ Direct Bury <br />Contained in Sump <br />❑ Direct Bury <br />❑X Contained in Sump <br />❑ Direct Bury <br />❑Contained in Sump <br />Bucket Diameter: <br />11 <br />11 <br />11 <br />Bucket Depth: <br />13 <br />13 <br />13 <br />Wait time between applying <br />vacuum/water and starting test: <br />Test Start Time (TI ): <br />1330 <br />1330 <br />1330 <br />Initial Reading (Rt-)': <br />11 <br />11.5 <br />11 <br />Test End Time (TF ): <br />1430 <br />1430 <br />1430 <br />Final Reading (RF ): <br />11 <br />11.5 <br />11 <br />Test Duration: <br />1 HR <br />1 HR <br />1 HR <br />Change in Reading R F- Ri ): <br />0 <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />0 <br />0 <br />0 <br />Test Result. . <br />Pass �'Fail <br />Pass Fail <br />K'f `Pass�`Fail <br />Pass Fail <br />Comments - (include information on repairs made prior to testing, and recommended follow-up forfailed 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: -Z/ Date: 01/08/2008 <br />I State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements <br />