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SWRCB, January 2006 <br />9. 1 Bucket Testing eo 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' 1 <br />Facility Name: SHELL # 136186 <br />Date of Testing: 12 / 2 2 / 2 0 0 9 <br />Facility Address: 3725 N. TRACY BLVD , TRACY, CA, 95376 <br />Facility Contact: MANAGER <br />I Phone: (2 0 9) 835-7608 <br />Date Local Agency Was Notified of Testing : 12 / 16 / 2 0 0 9 <br />Name of Local Agency Inspector (if present during testing): MICHELLE HENRY <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: TANKNOLOGY, INC. <br />Technician Conducting Test: CHARLES FERRUCCI <br />Credentials I : <br />❑X <br />CSLB Contractor <br />E <br />ICC Service Tech. 11 SWRCB Tank Tester <br />E <br />Other (Spec) i cc <br />License Number: 5323096 -UT <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 />12/22/2009 <br />I State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: <br />X❑ Hydrostatic <br />❑ Vacuum <br />❑ Other <br />Test Equipment Used: WATER <br />TAPE MEASURE <br />Equipment Resolution: l / 16" <br />EMEMEM <br />Identify Spill Bucket(By Tank <br />1 1 REG FILL <br />2 1 REG VAPOR <br />3 2 PLU FILL 4 <br />2 PLU VAPOR <br />Number, Stored Product, etc.) <br />Direct Bury <br />Direct Bury <br />❑ Direct Bury Direct Bury <br />Bucket Installation Type: <br />Contained in Sump <br />® Contained in Sump <br />xI Contained in SumpXQ Contained in Sump <br />Bucket Diameter: <br />11 3/4 <br />11 <br />11 <br />11 <br />Bucket Depth: <br />13 3/4 <br />13 <br />13 3/4 <br />13 <br />Wait time between applying <br />1 MIN <br />1 MIN <br />1 MIN <br />1 MIN <br />vacuum/water and starting test: <br />Test Start Time (TI ): <br />1000 <br />1120 <br />1000 <br />1000 <br />Initial Reading (RI ): <br />13 3/4 <br />13 <br />13 3/4 <br />13 <br />Test End Time (TF ): <br />1100 <br />1220 <br />1100 <br />1100 <br />Final Reading (RF ): <br />13 3/4 <br />13 <br />13 3/4 <br />13 <br />Test Duration: <br />1 HR <br />1 HR <br />1 HR <br />1 HR <br />Change in Reading (R F - RI ): <br />0 <br />0 <br />0 <br />0 <br />Pass/Fail Threshold or <br />0 <br />0 <br />0 <br />0 <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: <br />12/22/2009 <br />I State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements <br />