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SWRCB, January 2006 <br />9. 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 />Facility Name: SHELL # 136186 <br />Date of Testing: 02/02/200-9 <br />Facility Address: 3725 N. TRACY BLVD TRACY, CA, 95376 <br />Facility Contact: MANAGER <br />Phone: (2 0 9) 835-7608 <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (if present during testing): MICHELLE HENRY <br />2. TESTING CONTRACTOR O . <br />Company Name: TANKNOLOGY, INC. <br />Technician Conducting Test: BRYAN KEYS <br />Credentials 1: <br />❑ <br />CSLB Contractor <br />[:] <br />ICC Service Tech. <br />E <br />SWRCB Tank Tester <br />[:] <br />Other (Specify) <br />License Number: 0 7 -17 3 5 <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: <br />El Hydrostatic Vacuum <br />1:1 Other <br />Test Equipment Used: TEST FLUID, TAPE MEASURE <br />Equipment Resolution: VISUAL <br />Identify Spill Bucket(By Tank <br />Number, Stored Product, etc) <br />1 3 PRE FILL 2 3 PRE VAPOR <br />3 4 DIE FILL 4 <br />Bucket Installation Type: <br />Direct Bury F-1DirectBury <br />Contained in Sump X❑ Contained in SumpXQ <br />❑ Direct Bury Direct Bury <br />Contained in Sump ❑ Contained in Sump <br />Bucket Diameter: <br />14 14 <br />14 <br />Bucket Depth: <br />14 14 <br />14 <br />Wait time between applying <br />vacuum/water and starting test: <br />1 MIN 1 MIN <br />1 MIN <br />Test Start Time (TI ): <br />1236 1338 <br />1236 <br />Initial Reading (RI ): <br />12 7/8 12 3/8 <br />13 <br />Test End Time (TF ): <br />1336 1438 <br />1336 <br />Final Reading (RF }: <br />12 7/8 12 3/8 <br />13 <br />Test Duration: <br />1 HR 1 HR <br />1 HR <br />Change in Reading (R F - RI ): <br />0 0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />VISUAL LOSS VISUAL LOSS <br />VISUAL LOSS <br />NEESE= <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: 02/02/2009 <br />I State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements <br />