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SWRCB,January 2006 <br /> 9. l Bucket Testing epo arm <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 #9 9 8 4 0 Date of Testing: 02/11/2010 <br /> Facility Address: 4344 E WATERLOO RD @ 99, STOCKTON, CA, 95215 <br /> Facility Contact: MANAGER Phone: (2 0 9) 93 1-2186 <br /> Date Local Agency Was Notified of Testing <br /> Name of Local Agency Inspector(if present during testing): TRAM <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: BRIAN MCPHEELY <br /> Credentials :❑CSLB Contractor ❑X ICC Service Tech. ❑SWRCB Tank TesterX❑Other(Specify) ICC <br /> License Number: 8010965-UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: Hydrostatic ❑ Vacuum ❑ Other <br /> Test Equipment Used:WATER Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1 1 SUP FILL 2 3 REG FILL 3 4 <br /> Number, Stored Product, etc) <br /> Bucket Installation Type: ®Direct Bury ®Direct Bury ❑Direct Bury F-1Direct Bury <br /> ❑Contained in Sump ❑Contained in Sump ❑Contained in Sump ❑Contained in Sump <br /> Bucket Diameter: 12 12 <br /> Bucket Depth: 13 1/2 14 1/2 <br /> Wait time between applying 5MIN 5MIN <br /> vacuum/water and starting test: <br /> Test Start Time(TI ): 1:35 1:35 <br /> Initial Reading(RI ): 13 9/16 13 3/4 <br /> Test End Time(TF ): 2:35 2:35 <br /> Final Reading(R F ): 13 9/16 13 3/4 <br /> Test Duration: 60MIN 60MIN <br /> Change in Reading(R F-RI ): 0 0 <br /> Pass/Fail Threshold or NO VISUAL NO VISUAL <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: 23,-r- Date: 02/11/2010 <br /> I State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements <br />