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SWRCB,January 2006 <br /> 9. SvW Bucket Testing Reporvorm <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: CHEVRON #208117 Date of Testing: 02/11/2 011 <br /> Facility Address: 755 S. TRACY BLVD TRACY, CA, 95376 <br /> Facility Contact: MGR - MARIA Phone: (2 0 9) 830-0370 <br /> Date Local Agency Was Notified of Testing <br /> Name of Local Agency Inspector(if present during testing): Thuy <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: STEVEN WILLEMS <br /> Credentials): a CSLB Contractor ❑X ICC Service Tech. ❑SWRCB Tank Tester E Other(Spec) icc <br /> License Number: 8016974 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: El Hydrostatic ❑ Vacuum ❑ Other <br /> Test Equipment Used: tape measure Equipment Resolution:0 loss <br /> Identify Spill Bucket(By Tank 1 1 SUP FILL 2 2 UNL FILL 3 4 <br /> Number, Stored Product, etc) <br /> ❑Direct Bury ❑Direct Bury ❑Direct Bury ❑Direct Bury <br /> Bucket Installation Type: ®Contained in Sump X❑Contained in Sump ❑Contained in Sump ❑ Contained in Sump <br /> Bucket Diameter: 1211 1211 <br /> Bucket Depth: 12 .7511 12.511 <br /> Wait time between applying 5 mins 5 mins <br /> vacuum/water and starting test: <br /> Test Start Time(TI ): 9:42 9:42 <br /> Initial Reading(RI ): 12.7511 12 .511 <br /> Test End Time(TF ): 10:42 10:42 <br /> Final Reading(RF ): 12 .7511 12.511 <br /> Test Duration: 1 hour 1 hour <br /> Change in Reading(R F-RI ): 0 0 <br /> Pass/Fail Threshold or 0 loss 0 loss <br /> Criteria: <br /> ji 1i <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: CS Date: 02/11/2011 <br /> I State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements <br />