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SWRCB,January 2006 <br /> 9. 11 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(if applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: CHEVRON 208118 Date of Testing: 03/13/2009 <br /> Facility Address: 3355 E. HAMMER LANE @ HOLMAN RD, STOCKTON, CA, 95212 <br /> Facility Contact: MANAGER Phone: (2 0 9) 477-3 699 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): GARRETT BACKUS <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: KRISTOPHER BELL <br /> Credentials): ❑CSLB Contractor El ICC Service Tech. 11 SWRCB Tank Tester El Other(Spec) <br /> License Number: 5297793-UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: M Hydrostatic ❑ Vacuum 0 Other <br /> Test Equipment Used:TAPE MEASRE Equipment Resolution:NO VISABLE LOSS <br /> Identify Spill Bucket(By Tank 1 1 SUP FILL 2 2 UNL FILL 3 4 <br /> Number, Stored Product, etc) <br /> Bucket Installation Type: X❑Direct Bury XQ Direct Bury ❑Direct Bury Direct Bury <br /> ❑Contained in Sump ❑Contained in Sump ❑Contained in Sump ❑Contained in Sump <br /> Bucket Diameter: 1411 1411 <br /> Bucket Depth: 14 1/211 14 3/411 <br /> Wait time between applying 1 MIN 1 MIN <br /> vacuum/water and starting test: <br /> Test Start Time(TI ): 8:55 8:55 <br /> Initial Reading(RI ): 14 1/211 14 3/411 <br /> Test End Time(TF ): 9:55 9:55 <br /> Final Reading(R F ): 14 1/211 14 3/4" <br /> Test Duration: 1 HR 1 HR <br /> Change in Reading(R F-RI ): <br /> 0" 0" <br /> Pass/Fail Threshold or 0" Oil <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: -1-2111 - •r��r� Date: 03/13/2009 <br /> I State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements <br />