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SWRCB,January 2006 <br /> 9. Sftl Bucket Testing Reporworm <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: CONOCO PHILLIPS #2705446 1 DateofTesting: 05/19/2008 <br /> Facility Address: 1403 COUNTRY CLUB BLVD , STOCKTON, CA, 95204 <br /> Facility Contact: MANAGER Phone: (2 0 9) 943-2082 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): RAY VON FLUE <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: KRISTOPHER BELL <br /> Credentials): ❑CSLB Contractor E ICC Service Tech. ❑SWRCB Tank Tester ❑Other(Specify) <br /> License Number: 5297793-UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: El Hydrostatic ❑ Vacuum ❑ Other <br /> Test Equipment Used:TAPE MEASURE Equipment Resolution:NO VISABLE LOSS <br /> Identify Spill Bucket(By Tank 3 SUP FILL z 1 DIE FILL 3 4 <br /> Number,Stored Product, etc) <br /> Bucket Installation Type: ❑X Direct Bury ]Direct Bury ❑Direct Bury ❑Direct Bury <br /> ❑Contained in Sump ❑Contained in Sump ❑Contained in Sump ❑Contained in Sump <br /> Bucket Diameter: 1411 1411 <br /> Bucket Depth: 13" 1411 <br /> Wait time between applying 1 MIN 1 MIN <br /> vacuum/water and starting test: <br /> Test Start Time(TI ): 13 :03 13:08 <br /> Initial Reading(RI ): 12 1/211 13 1/411 <br /> Test End Time(TF ): 14:03 14 :08 <br /> Final Reading(RF ): 12 1/2" 13 1/4" <br /> Test Duration: 1 HR 1 HR <br /> Change in Reading(R F-RI ): <br /> 0" 0" <br /> Pass/Fail Threshold or 01, oil <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: �� Date: 05/19/2008 <br /> 4 <br /> I State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements <br />