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SWRCB, January 2006 <br />l SIDI Bucket TestingRepor*orm <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: SHELL # 136186 <br />Date of Testing: 02/20/2008 <br />Facility Address: 3725 N. TRACY BLVD TRACY, CA, 95376 <br />Facility Contact: MANAGER <br />Phone: (2 0 9) 835-7608 <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: SCOTT HOLMAN <br />Credentials I : <br />❑ <br />CSLB Contractor <br />Ej <br />ICC Service Tech. ❑ SWRCB Tank Tester <br />❑ <br />Other (Specify) <br />License Number: <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: <br />Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: WATER <br />Equipment Resolution: <br />Identify Spill Bucket(By Tank <br />1 3 PRE FILL 2 3 PRE VAPOR 3 4 DIE FILL 4 <br />Number, Stored Product, etc) <br />Direct Bury ElDirect Bury <br />E]Direct Bury ❑ Direct Bury <br />Bucket Installation Type: <br />❑X Contained in Sump R❑ Contained in Sump <br />X❑ Contained in Sump ❑ Contained in Sump <br />Bucket Diameter: <br />1211 1211 <br />1211 <br />Bucket Depth: <br />1411 1411 <br />1411 <br />Wait time between applying <br />1M 1M <br />1M <br />vacuum/water and starting test: <br />Test Start Time (TI ): <br />10:10 11:30 <br />10:10 <br />Initial Reading (RI ): <br />12.511 12.511 <br />12.511 <br />Test End Time (TF ): <br />11:10 12 : 3 0 <br />11:10 <br />Final Reading (RF ): <br />12.511 12.511 <br />12.511 <br />Test Duration: <br />1HR 1HR <br />1HR <br />Change in Reading (R F - RI ): <br />0 0 <br />0 <br />Pass/Fail Threshold or <br />0 0 <br />0 <br />Criteria: <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: <br />9f Date: 02/20/2008 <br />i <br />I State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements <br />