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SWRCB,January 2006 <br /> 9. S 1 Bucket Testing Reporeorm <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 /> FacilityName: CHEVRON 208118 Date of Testing: 04/16/2008 <br /> Facility Address: 3355 E. HAMMER LANE STOCKTON, CA, 95212 <br /> Facility Contact: MANAGER Phone: (2 0 9) 477-3699 <br /> Date Local Agency Was Notified of Testing <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: KELVIN CRUZ <br /> Credentials): ❑CSLB Contractor a ICC Service Tech. ❑SWRCB Tank Tester ❑X Other(Specify) SPILL BKT <br /> License Number: 5254041-UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: Hydrostatic ❑ Vacuum F-1 Other <br /> Test Equipment Used: Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1 1 SUP FILL 2 2 UNL FILL 3 4 <br /> Number,Stored Product, etc) <br /> QX Direct Bury 0 Direct Bury ❑Direct Bury ❑Direct Bury <br /> Bucket Installation Type: <br /> ❑Contained in Sump ❑Contained in Sump ❑Contained in Sump ❑Contained in Sump <br /> Bucket Diameter: 12 12 <br /> Bucket Depth: 15 15 <br /> Wait time between applying 1MIN 1MIN <br /> vacuum/water and starting test: <br /> Test Start Time(TI ): 0930 0930 <br /> Initial Reading(RI ): 12.25 12.25 <br /> Test End Time(TF ): 1030 1030 <br /> Final Reading(RF ): 12.25 12.25 <br /> Test Duration: 1HR 1HR <br /> Change in Reading(R F-RI ): 0 0 <br /> Pass/Fail Threshold or <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: Date: 04/16/2008 <br /> I State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements <br />