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SWRCB,January 2006 <br /> . 011 Bucket Testing Repo or <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 201761 Date of Testing: 01/2 5/2 010 <br /> Facility Address: 1103 S. MAIN ST. , MANTECA, CA, 95337 <br /> Facility Contact: MGR - MARIE Phone: (2 0 9) 825-0174 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): j e f f <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: STEVEN WILLEMS <br /> Credentials 1: E CSLB Contractor E ICC Service Tech. ❑SWRCB Tank Tester Other(Specify) i cc <br /> License Number: 8016974 - UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: X❑ Hydrostatic ❑ Vacuum ❑ Other <br /> Test Equipment Used: tape measure Equipment Resolution:1/8 inch <br /> NONE= EMENESIM <br /> Identify Spill Bucket(By Tank 1 SUP FILL Z 2 REG FILL 3 3 REG FILL 4 1 SUP FILL <br /> Number,Stored Product, etc) <br /> Direct Bury F-�Direct Bury 0 Direct Bury F-1Direct Bury <br /> Bucket Installation Type: <br /> XO Contained in Sump XQ Contained in Sump XQ Contained in Sump ❑X Contained in Sump <br /> Bucket Diameter: 12 12 12 12 <br /> Bucket Depth: 12 .5 13 12.5 13 <br /> Wait time between applying 5 mins 5 mins 5 mins 5 mins <br /> vacuum/water and starting test: <br /> Test Start Time(TI ): 090 7 1030 1030 1030 <br /> Initial Reading(RI ): 12.5 13 11.5 12 <br /> Test End Time(TF ): 1007 1130 1130 1130 <br /> Final Reading(RF ): 12 13 11.5 12 <br /> Test Duration: 1 hour 1 hour 1 hour 1 hour <br /> Change in Reading(R F-RI }: 0 0 0 0 <br /> Pass/Fail Threshold or visual visual visual visual <br /> Criteria: <br /> Comments - (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> 91 fill cap was leaking <br /> replaced fill cap with new cap <br /> retested SB, and passed. <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: V�J Date: 01/25/2010 <br /> 1 State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements <br />