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SWRCB,January 2006 <br /> 9. 1 Bucket Testing Repo or <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 #99840 Date of Testing: 02/20/2009 <br /> Facility Address: 4344 WATERLOO RD @ 99, STOCKTON, CA, 95215 <br /> Facility Contact: MANAGER Phone: (2 0 9) 93 1-218 6 <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: BRIAN MCPHEELY <br /> Credentials 1: []CSLB Contractor E ICC Service Tech. 0 SWRCB Tank Tester [:]Other(Specify) <br /> License Number: 8 010 9 6 5-u t <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: Hydrostatic ❑ Vacuum ❑ Other <br /> Test Equipment Used:Water Equipment Resolution: <br /> OEM Em No= <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: Q Direct Bury X❑Direct Bury ❑Direct Bury ❑Direct Bury <br /> ❑Contained in Sump ❑Contained in Sump ❑Contained in Sump ❑Contained in Sump <br /> Bucket Diameter: 11 11 <br /> Bucket Depth: 14 14 <br /> Wait time between applying 5 min 5 min <br /> vacuum/water and starting test: <br /> Test Start Time(Tl ): 2 :02 2 :02 <br /> Initial Reading(Rl ): 13 3/8 13 3/8 <br /> Test End Time(TF ): 3 :02 3 :02 <br /> Final Reading(RF ): 13 3/8 13 3/8 <br /> Test Duration: 60min 60min <br /> Change in Reading(R F-Rl ): 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: z Date: 02/20/2009 <br /> 1 State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements <br />