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SWRCB, January 2006 <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 ownerloperator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: CHEVRON #201383 (N-2515) <br />DateofTesting: 04/07/2008 <br />Facility Address: 1960 W. 11TH STREET TRACY, CA, 95376 <br />Facility Contact: MGR - HELEN <br />Phone: (2 0 9) 8 3 6 - 3181 <br />Date Local Agency Was Notified of Testing <br />Name of Local Agency Inspector (if present during testing): <br />2. TESTING O • INFORMATION <br />Company Name: TANKNOLOGY, INC. <br />Technician Conducting Test: DANIEL ORTIZ <br />Credentials 1: <br />0 <br />CSLB Contractor <br />❑ <br />ICC Service Tech. <br />❑ <br />SWRCB Tank Tester <br />❑ <br />Other (Specify) <br />License Number: <br />"riAIIIYX91 E"SOall]11 ENIrole <br />Test Method Used: <br />Hydrostatic <br />❑ Vacuum <br />❑ Other <br />Test Equipment Used: <br />Equipment Resolution: <br />Identify Spill Bucket(By Tank <br />1 1 SUP FILL <br />2 2 PLU FILL <br />3 3 REG FILL 4 <br />Number, Stored Product, etc) <br />❑ Direct Bury <br />F-1DirectBury <br />❑ Direct Bury ❑ Direct Bury <br />Bucket Installation Type: <br />0 Contained in Sump <br />0 Contained in Sump <br />Q Contained in Sump ❑ Contained in Sump <br />Bucket Diameter: <br />13 <br />13 <br />13 <br />Bucket Depth: <br />14 <br />14 <br />14 <br />Wait time between applying <br />1:00 <br />1:00 <br />1:00 <br />vacuum/water and starting test: <br />Test Start Time (TI ): <br />9:34 <br />9: 34 <br />9:34 <br />Initial Reading (R I ): <br />11 1/4 <br />11 1/2 <br />11 1/2 <br />Test End Time (TF ): <br />10 :40 <br />10:4 0 <br />10 :4 0 <br />Final Reading (RF ): <br />11 1/4 <br />11 1/2 <br />11 1/2 <br />Test Duration: <br />1: 07 <br />1: 07 <br />1: 07 <br />Change in Reading (R F - RI ): <br />0 <br />0 <br />0 <br />Pass/Fail Threshold or <br />1/8 <br />1/8 <br />1? 8 <br />Criteria: <br />ii i all <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 in this <br />report is true, accurate, and in full compliance with legal requirements. <br />/ncontained <br />Technician's Signature: Jul n-lk <br />Date: 04/07/2008 <br />1 State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements <br />