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SWRCB,January 2006 <br /> 9. SPI 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 /> Facility Name: CHEVRON 201761 Date of Testing: 01/21/2 011 <br /> Facility Address: 1103 S. MAIN ST. PERMIT NUMB. N-3315, MANTECA, CA, 95337 <br /> Facility Contact: MGR - MARIE Phone: (2 0 9) 825-0174 <br /> Date Local Agency Was Notified of Testing <br /> Name of Local Agency Inspector(if present during testing): Muniappa N. <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. 1:1 SWRCB Tank Tester E Other(Specify) i cc <br /> License Number: 8016974 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: El Hydrostatic Vacuum ❑ Other <br /> Test Equipment Used:tape measure Equipment Resolution:0 loss <br /> Identify Spill Bucket(By Tank 1 1 SUP FILL 2 2 REG FILL 3 3 REG FILL 4 <br /> Number, Stored Product, etc.) <br /> Bucket Installation Type: Direct Bury Direct Bury F-j Direct Bury ❑ Direct Bury <br /> QX Contained in SumpXQ Contained in SumpXQ Contained in Sump ❑ Contained in Sump <br /> Bucket Diameter: <br /> 12" 12" 12" <br /> Bucket Depth: 12.7511 13.25" 1211 <br /> Wait time between applying 5 mins 5 mins 5 mins <br /> vacuum/water and starting test: <br /> Test Start Time(TI ): 10:00 10:00 10:0 0 <br /> Initial Reading(RI ): 12.7511 13.2511 1211 <br /> Test End Time(TF ): 11:00 11:00 11:00 <br /> Final Reading(R F ): 12.7 5" 13.25" 1211 <br /> Test Duration: 1 hour 1 hour 1 hour <br /> Change in Reading(R F -RI ): 0 0 0 <br /> Pass/Fail Threshold or 0 loss 0 loss 0 loss <br /> Criteria: <br /> 77 <br /> �StRSuIt.: F, ii <br /> T+#tI # s � PSS Pa3 1xtl'. <br /> - ... F, ; <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: 01/21/2011 <br /> IQ+.+.1-- ...,.i«o,.,,l.,f:...,.. .1...,,.r..,.....o.,rl.,«o..,.:«o ro..r:,,.,+..t—--F «.. A 1...., ......1;,r-A ...,,,r«.,..r..« LF—....... 1......1 <br />