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SWRCB, January 2006 <br />48 9.1 Bucket Testing Repo orm <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 />Facility Name: SHELL # 136186 <br />Date of Testing: 12/22/2009 <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: 12/16/2009 <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 1: <br />[�] <br />CSLB Contractor <br />X❑ <br />ICC Service Tech. <br />❑ <br />SWRCB Tank Tester E Other (Spec) i cc <br />License Number: 5323096 -UT <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: <br />Z Hydrostatic <br />❑ Vacuum Other <br />Test Equipment Used: WATER <br />TAPE MEASURE <br />Equipment Resolution: l / 16" <br />Identify Spill Bucket(By Tank <br />i 3 PRE FILL <br />2 3 PRE VAPOR 3 4 DIE FILL 4 <br />Number, Stored Product, etc.) <br />Direct Bury <br />Direct Bury ❑ Direct Bury Direct Bury <br />Bucket Installation Type: <br />❑x Contained in SumpX❑ <br />Contained in SumpxQ Contained in Sump ❑ Contained in Sump <br />-Bucket Diameter: <br />11 <br />11 11 <br />Bucket Depth: <br />13 <br />13 13 <br />Wait time between applying <br />1 MIN <br />1 MIN 1 M I N <br />vacuum/water and starting test: <br />Test Start Time (Tl ): <br />0830 <br />0830 0830 <br />Initial Reading (RI ): <br />13 <br />13 13 <br />Test End Time (TF ): <br />0930 <br />0930 0930 <br />Final Reading (RF ): <br />13 <br />13 13 <br />Test Duration: <br />1 HR <br />1 HR 1HR <br />Change in Reading (R F - Rl ): <br />0 <br />0 0 <br />Pass/Fail Threshold or <br />0 <br />0 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 <br />report is true, accurate, and in full compliance with legal requirements. <br />Technician's Signature: <br />�,L <br />Date: 12/22/2009 <br />1 State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements <br />