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SWRCB, January 2006 <br />9. L 11 Bucket Testing Repoi � orm <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 />Date of Testing: 09/15/2009 <br />Facility Address: 10858 TRINITY PKWY STOCKTON, CA, 95210 <br />Facility Contact: MANAGER <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): N/A <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: TANKNOLOGY, INC. <br />Technician Conducting Test: BRYAN KEYS <br />Credentials 1: <br />❑ <br />CSLB Contractor <br />❑ <br />ICC Service Tech. <br />❑x <br />SWRCB Tank Tester <br />❑ <br />Other (Spec) <br />License Number: 0 7 -17 3 5 <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: X❑ Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: VACUUM TEST UNIT <br />Equipment Resolution: INCHES OF WATER <br />Identify Spill Bucket(By Tank <br />Number, Stored Product, etc) <br />1 1 UNL FILL <br />2 <br />3 <br />4 <br />Bucket Installation Type: <br />❑ Direct Bury <br />X❑ Contained in Sump <br />❑ Direct Bury <br />❑ Contained in Sump <br />❑ Direct Bury <br />❑ Contained in Sump <br />❑ Direct Bury <br />❑ Contained in Sump <br />Bucket Diameter: <br />12 <br />Bucket Depth: <br />14 <br />Wait time between applying <br />vacuum/water and starting test: <br />1 MIN <br />Test Start Time (TI ): <br />1621 <br />Initial Reading (Ri ): <br />-30 <br />Test End Time (TF ): <br />1622 <br />Final Reading (RF ): <br />-28 <br />Test Duration: <br />1 MIN <br />Change in Reading (R F - RI ): <br />2 <br />Pass/Fail Threshold or <br />Criteria: <br />4 <br />Test Result: <br />❑ Pass ❑ Fail <br />❑ Pass ❑ .Fail <br />❑ Pass ❑ Fail <br />❑ Pass ❑ Fail, <br />Comments - (include information on repairs made prior to testing, and recommended follow-up for Jailed tests) <br />NOTICED BULGE IN BUCKET SIDE, REMOVED PRIMARY LID AND MADE ADJUSTMENT TO BAND CLAMP ON <br />SECONDARY LID, REASSEMBLED SUMP LID AND TESTED; PASS <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: Z4= 7�— Date <br />09/15/2009 <br />I State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements <br />