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� <br />9. Sp1!I Bucket Testing Report%rm 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 />Facility Name: CHEVRON 3 0 7 7 0 9 <br />1 Date of Testing: 04/29/2011 <br />Facility Address: 10858 TRINITY PKWY , STOCKTON, CA, 95210 <br />Facility Contact: MANAGER (N-7462-1-10) <br />Phone: (2 0 9) 952-2213 <br />Date Local Agency Was Notified of Testing : / / <br />Name of Local Agency Inspector (if present during testing): GARRET BACKUS <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: TANKNOLOGY, INC. <br />Technician Conducting Test: TIMOTHY ELEBECK <br />Credentials): <br />❑ CSLB Contractor <br />a ICC Service Tech. <br />❑ <br />SWRCB Tank Tester E Other (Spec) ICC <br />License Number: 8001435 <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: ❑ Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: NITROGEN DONUT <br />Equipment Resolution: 4 IWC <br />3 3 DIE FILL <br />4 <br />Identify Spill Bucket(By Tank <br />Number, Stored Product, etc.) <br />1 1 UNL FILL <br />2 2 PRE FILL <br />Bucket Installation Type: <br />❑ Direct Bury <br />EEContained in Sump[i] <br />E] Direct Bury <br />Contained in Sump <br />❑ Direct Bury <br />EZ Contained in Sump <br />El Direct Bury <br />❑ Contained in Sump <br />Bucket Diameter: <br />12 <br />12 <br />12 <br />Bucket Depth: <br />14 <br />14 <br />14 <br />Wait time between applying <br />vacuum/water and starting test: <br />5MIN <br />5MIN <br />5MIN <br />Test Start Time (TI ): <br />10 : 0 0 <br />10:10 <br />10 : 2 0 <br />Initial Reading (RI ): <br />30 <br />30 <br />30 <br />Test End Time (TF ): <br />10: 01 <br />10: 11 <br />10:21 <br />Final Reading (RF ): <br />30 <br />30 <br />30 <br />Test Duration: <br />1M I N <br />1 M IN <br />1 M IN <br />Change in Reading (R F- R 1 ): <br />0 <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />p <br />p <br />p <br />Test Result:❑Pass <br />❑ Fail <br />1flPass ❑ Fail <br />EPass ❑ Fail <br />❑ Pass ❑ Fail <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:-�� LAA ,IC Date: <br />04/29/2011 <br />I State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements <br />