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SWRCB,January 2006 <br /> 9. SI&I 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(f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> FacilityName: CHEVRON #99840 Date of Testing: 01/25/2011 <br /> Facility Address: 4344 E WATERLOO RD @ 99, STOCKTON, CA, 95215 <br /> Facility Contact: MANAGER Phone: (2 0 9) 931-2186 <br /> Date Local Agency Was Notified of Testing <br /> Name of Local Agency Inspector(if present during testing): Jeff W. <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: STEVEN WILLEMS <br /> Credentials I: E CSLB Contractor E ICC Service Tech. 11 SWRCB Tank Tester E Other(Spec) i cc <br /> License Number: 8016974 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: El Hydrostatic Vacuum 1:1 Other <br /> Test Equipment Used:tape measure Equipment Resolution:0 loss <br /> MENEM <br /> Identify Spill Bucket(By Tank 1 1 SUP FILL Z 3 REG FILL 3 4 <br /> Number, Stored Product, etc.) <br /> Bucket Installation Type: ❑X Direct Bury X❑ Direct Bury F-1Direct Bury ® Direct Bury <br /> ❑ Contained in Sump ❑ Contained in Sump ❑Contained in Sump ❑ Contained in Sump <br /> Bucket Diameter: 1211 121v <br /> Bucket Depth: 14" 13" <br /> Wait time between applying 5 mins 5 mins <br /> vacuum/water and starting test: <br /> Test Start Time(TI ): 9:50 9:5 0 <br /> Initial Reading(RI ): <br /> 14" 13" <br /> Test End Time(TF ): 10:50 10:50 <br /> Final Reading(R F ): 14" 13" <br /> Test Duration: 1 hour 1 hour <br /> Change in Reading(R F -RI ): 0 0 <br /> Pass/Fail Threshold or 0 loss 0 loss <br /> Criteria: <br /> W, MIL <br /> Ss g <br /> El <br /> Fail <br /> aj <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: 01/25/2011 <br /> tChnhn 1-- —4--l-+;— A-nn4 n..rrun4�ar r.n n..ivo fn n4inn fn l.o ranv�rer orl�+<r n n.a n�:�na nnv.Mnn4nv L7 naa.oa.ca• �nnn�re n..:rnay.ov.4r <br />