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SWRCB, January 2006 <br />9. SO Bucket Testing Reporlworm <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 />0 1 <br />Facility Name: CHEVRON #201383 (N-2515) <br />Date of Testing: 02/04/2011 <br />Facility Address: 1960 W. 11TH STREET @ CORRAL HOLLOW, TRACY, CA, 95376 <br />Facility Contact: MGR - HELEN <br />Phone: (2 0 9) 836-3181 <br />Date Local Agency Was Notified of Testing <br />Name of Local Agency Inspector (if present during testing): Thuy <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: TANKNOLOGY, INC. <br />Technician Conducting Test: STEVEN WILLEMS <br />Credentials 1: <br />❑x <br />CSLB Contractor <br />E ICC Service Tech. ❑ SWRCB Tank Tester <br />E <br />Other (Specify) icc <br />License Number: 8016974 <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: [K] Hydrostatic ❑ Vacuum <br />❑ Other <br />Test Equipment Used: tape measure <br />Equipment Resolution: 0 loss <br />Identify Spill Bucket(By Tank 1 1 SUP FILL Z 2 PLU FILL <br />Number, Stored Product, etc) <br />3 3 REG FILL 4 <br />Direct Bury El Direct Bury <br />Bucket Installation Type: ❑ Contained in Sump x0 Contained in SumpX❑ <br />F-1DirectBury ❑ Direct Bury <br />Contained in Sump ❑ Contained in Sump <br />Bucket Diameter: 1211 1211 <br />1211 <br />Bucket Depth: 1211 12.7511 <br />12.7511 <br />Wait time between applying 5 mins 5 mins <br />vacuum/water and starting test: <br />5 mins <br />Test Start Time (Tl ): 10:16 10:16 <br />10:16 <br />Initial Reading (RI ): 1211 12.7511 <br />12.7511 <br />Test End Time (TF ): 11:16 11:16 <br />11:16 <br />Final Reading (R F ): 1211 12.7511 <br />12.7511 <br />Test Duration: 1 hour 1 hour <br />1 hour <br />Change in Reading (R F - Rl ): 0 0 <br />0 <br />Pass/Fail Threshold or 0 loss 0 loss 0 loss <br />Criteria: <br />SIM <br />Comments - (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />replaced 87 and 91 spill bucket fill caps due to wrong <br />cap on tiii riser. <br />replaced 89 spill bucket fill cap, due to gasket missing on fill cap. visual failure. <br />replaced all fill caps on all three grades. <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: 02/04/2011 <br />1 State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements <br />