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SWRCB,January 2006 <br /> 9. MMI Bucket Testing Reor 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: CHEVRON #99840 Date of Testing: 03/10/2008 <br /> Facility Address: 4344 WATERLOO RD , STOCKTON, CA, 95210 <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: RHOME DESBIENS <br /> Credentials 1: ❑CSLB Contractor E ICC Service Tech. ❑SWRCB Tank Tester []Other(Specify) <br /> License Number: <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ❑ Hydrostatic Vacuum 0 Other <br /> Test Equipment Used:vacuum donut Equipment Resolution: <br /> Identify Spill Bucket(By Tank <br /> 1 3 REG FILL 2 1 SUP FILL 3 4 <br /> Number, Stored Product, etc) <br /> X❑Direct Bury XQ Direct Bury ❑Direct Bury F-1Direct Bury <br /> Bucket Installation Type: <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 <br /> vacuum/water and starting test: <br /> Test Start Time(Tl ): 1000 1020 <br /> Initial Reading(RI ): <br /> -30" -30" <br /> Test End Time(TF ): 1001 1021 <br /> Final Reading(RF ): <br /> -29" -29" <br /> Test Duration. lmin lmin <br /> Change in Reading(R F-RI ): 1 1 <br /> Pass/Fail Threshold or 5 5 <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: Date: 03/10/2008 <br /> 1 State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements <br />