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SWRCB,January 2006 <br /> 9. S l Bucket Testing eor 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 /> FacilityName: CHEVRON #201383 (N-2515) Date of Testing: 02/27/2009 <br /> Facility Address: 1960 W. 11TH STREET TRACY, CA, 95376 <br /> Facility Contact: MGR - HELEN Phone: (2 0 9) 836-3181 <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: EDWIN BUECHLER <br /> Credentials I: ❑CSLB Contractor ❑ICC Service Tech. ❑SWRCB Tank Tester ❑Other(Specify) <br /> License Number: <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: x❑ Hydrostatic ❑ Vacuum ❑ Other <br /> Test Equipment Used: Equipment Resolution: <br /> IMENINNINEM <br /> Identify Spill Bucket(By TankF[:] <br /> REG FILL 2 3 REG VAPOR 3 4 <br /> Number, Stored Product, etc.) <br /> rect Bury E]Direct Bury ❑Direct Bury ❑Direct Bury <br /> Bucket Installation Type: Contained in Sump FX Contained in Sump ❑Contained in Sump ❑ Contained in Sump <br /> Bucket Diameter: 10.5 10.5 <br /> Bucket Depth: 11 11 <br /> Wait time between applying 5min 5min <br /> vacuum/water and starting test: <br /> Test Start Time(TI ): 9:00a 9:0 0 a <br /> Initial Reading(RI ): 10.5 10.75 <br /> Test End Time(TF ): 10:0 0 am 10:0 0 am <br /> Final Reading(RF ): 10.5 10.75 <br /> Test Duration: lhr lhr <br /> Change in Reading(R F-RI ): 0 0 <br /> Pass/Fail Threshold or 0 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: 0• Date: 02/27/2009 <br /> I State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements <br />