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SWRCB, January 2006 <br />PBucket Testing. 1 1 1 <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. FACILITY INFORMATION <br />Facility Name: SHELL CC # 136187 <br />Date of Testing: 07/10/2008 <br />Facility Address: 2375 WEST GRANT LINE ROAD , TRACY, CA, 95376 <br />Facility Contact: MANAGER <br />Phone: (2 0 9) 836-8908 <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: SCOTT HOLMAN <br />Credentials 1: <br />❑ <br />CSLB Contractor <br />[] <br />ICC Service Tech. <br />0 <br />SWRCB Tank Tester [] Other (Specify) <br />License Number: <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: <br />Hydrostatic <br />Vacuum 1:1 Other <br />Test Equipment Used: WATER <br />Equipment Resolution: <br />Identify Spill Bucket(By Tank <br />1 1 REG FILL <br />2 1 REG VAPOR <br />3 2 PLU FILL <br />4 2 PLU VAPOR <br />Number, Stored Product, etc) <br />Direct Bury <br />F-1Direct Bury <br />F-1Direct Bury <br />Ej Direct Bury <br />Bucket Installation Type: <br />X❑ Contained in Sump <br />XQ Contained in Sump <br />Contained in Sump <br />Contained in Sump <br />Bucket Diameter: <br />1211 <br />1211 <br />12" <br />1211 <br />Bucket Depth: <br />1411 <br />1411 <br />14 " <br />1411 <br />Wait time between applying <br />1M <br />1M <br />1M <br />1M <br />vacuum/water and starting test: <br />Test Start Time (Tl ): <br />9:30 <br />9:30 <br />9:30 <br />9: 3 0 <br />Initial Reading (Rl ): <br />12.511 <br />12.511 <br />12.511 <br />12.511 <br />Test End Time (TF ): <br />10 : 3 0 <br />10 : 3 0 <br />10 : 3 0 <br />10 : 3 0 <br />Final Reading (RF ): <br />12.511 <br />12.511 <br />12.511 <br />12.511 <br />Test Duration: <br />1HR <br />1HR <br />1HR <br />1HR <br />Change in Reading (R F - Rl ): <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 TECIINICIAN 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: <br />/� _ <br />Date: 07/10/2008 <br />1 State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements <br />