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SWRCB, January 2006 <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 />FacilityName: 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 I : <br />0 <br />CSLB Contractor <br />[] <br />ICC Service Tech. E] SWRCB Tank Tester ❑ Other (Specify) <br />License Number: <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: �i y� Date: <br />07/10/2008 <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 />El Hydrostatic <br />El Vacuum <br />❑ Other <br />Test Equipment Used: WATER <br />Equipment Resolution: <br />Identify Spill Bucket(By Tank <br />1 3 PRE FILL <br />Z 3 PRE VAPOR <br />3 4 DIE FILL 4 <br />Number, Stored Product, etc) <br />❑ Direct Bury <br />r-1DirectBury <br />❑ Direct Bury ❑ Direct Bury <br />Bucket Installation Type: <br />Contained in Sump <br />X❑ Contained in SumpX❑ <br />Contained in Sump ❑ Contained in Sump <br />Bucket Diameter: <br />1211 <br />1211 <br />12 " <br />Bucket Depth: <br />1411 <br />1411 <br />1411 <br />Wait time between applying <br />1M <br />1M <br />1M <br />vacuum/water and starting test: <br />Test Start Time (TI ): <br />9: 3 0 <br />9: 3 0 <br />9: 3 0 <br />Initial Reading (RI ): <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 />Final Reading (R F ): <br />12.511 <br />12.511 <br />12.511 <br />Test Duration: <br />1HR <br />1HR <br />1HR <br />Change in Reading (R F - RI ): <br />0 <br />0 <br />0 <br />Pass/Fail Threshold or <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: �i y� Date: <br />07/10/2008 <br />I State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements <br />