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SWRCB, January 2006 <br />9. SAI Bucket Testing epor 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 />Facility Name: CHEVRON #201383 <br />DateofTesting: 02/03/2012 <br />Facility Address: 1960 W. 11TH STREET @ CORRAL HOLLOW, TRACY, CA, 95376 <br />Facility Contact: HELEN - PERMIT: (N-2515-1-3) <br />Phone: (209) 836-3181 <br />Date Local Agency Was Notified of Testing : / / <br />Name of Local Agency Inspector (if present during testing): <br />2. TESTING CONTRACTOR / ' 1 <br />Company Name: TANKNOLOGY, INC. <br />Technician Conducting Test: TIMOTHY COULTER <br />Credentials : <br />a <br />CSLB Contractor <br />E ICC Service Tech. ❑ SWRCB Tank Tester <br />1fl <br />Other (Spec) UT -A <br />License Number: 5295244-734160 <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: ❑ Hydrostatic Vacuum 1:1 Other <br />Test Equipment Used: VACUUM DOUGHNUT <br />Equipment Resolution: <br />Identify Spill Buckep'By Tank <br />Number, Stored Product, etc.) <br />1 3 REG FILL <br />Z 2 PLU FILL <br />3 1 SUP FILL <br />4 <br />Bucket Installation Type: <br />Direct Bury <br />XQ Contained in SumpXQ <br />0 Direct Bury <br />Contained in Sump <br />Ej Direct Bury <br />FX-] Contained in Sump <br />0 Direct Bury <br />❑ Contained in Sump <br />Bucket Diameter: <br />10 <br />10 <br />10 <br />Bucket Depth: <br />10 <br />10 <br />10 <br />Wait time between applying <br />vacuum/water and starting test: <br />0 MINS <br />0 MINS <br />0 MINS <br />Test Start Time (TI ): <br />1015 <br />1016 <br />1018 <br />Initial Reading (RI ): <br />-30 <br />-30 <br />-30 <br />Test End Time (TF ): <br />1016 <br />1017 <br />1019 <br />Final Reading (RF ): <br />-30 <br />-30 <br />-30 <br />Test Duration: <br />1 MIN <br />1 MIN <br />1 MIN <br />Change in Reading (R F - RI ): <br />0 <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />0 <br />0 <br />0 <br />F <br />Test`Resutlt::; J max;, Ps ail �Et 1Pass r f I�tX71asa Fail <br />„.: „. <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: <br />02/03/2012 <br />IQ+. +. 1.,......, A «e..,,l.,r;...,« .4.. ,,..t —««o.,r1— «o..,,;«o roar;,,., f.. ho --r ..., A U. , ., --14;-4 —+—+— T-T—,o — 1-1 <br />