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SWRCB, January 2006 <br />9. l 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: SHELL CC # 13 618 7 <br />Date of Testing: 0 7 / 2 6 / 2 0 0 7 <br />Facility Address: 2375 WEST GRANT LINE ROAD TRACY, CA, 95376 <br />Facility Contact: MANAGER <br />Phone: (2 0 9) 8 3 6- 8 9 0 8 <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) : <br />� <br />CSLB Contractor <br />❑ICC <br />Service Tech. <br />❑SWRCB <br />Tank Tester <br />� <br />Other (Specify) SPILL BKTS <br />License Number: 14 2 4 <br />CERTIFICATION OF TEC)EINICIAN 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: 0 7/ 2 6/ 2 0 0 7 <br />1 State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements <br />3. SPILL BUCKET TESTING INFO TION <br />Test Method Used: <br />� Hydrostatic <br />❑ Vacuum <br />� Other <br />Test Equipment Used: FUEL <br />Equipment Resolution: <br />Identify Spill Bucket(By Tank <br />t 1 REG FILL <br />Z 2 PLU FILL <br />3 3 PRE FILL <br />a 4 DIE FILL <br />Number, Stored Product, etc.) <br />❑ Direct Bury <br />❑Direct Bury <br />❑Direct Bury <br />❑Direct Bury <br />Bucket Installation Type: <br />❑ Contained in Sump <br />❑Contained in Sump <br />❑Contained in Sump <br />❑Contained in Sump <br />Bucket Diameter: <br />10X11 <br />10X11 <br />10X11 <br />10X11 <br />Bucket Depth: <br />12 <br />12 <br />12 <br />12 <br />Wait time between applying <br />5MIN <br />5MIN <br />5MIN <br />5MIN <br />vacuum/water and starting test: <br />Test Start Time (TI ): <br />0900 <br />0900 <br />0900 <br />0900 <br />Initial Reading (RI ): <br />10 <br />10 <br />10 <br />10 <br />Test End Time (Tp ): <br />10 0 0 <br />10 0 0 <br />10 0 0 <br />10 0 0 <br />Final Reading (Rp ): <br />10 <br />10 <br />10 <br />10 <br />Test Duration: <br />1HR <br />iHR <br />1HR <br />1HR <br />Change in Reading (R p - RI ): <br />0 <br />0 <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />COmmerits - (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />CERTIFICATION OF TEC)EINICIAN 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: 0 7/ 2 6/ 2 0 0 7 <br />1 State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements <br />