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SWRCB, January 2006 <br />• 9. SIS Bucket Testing Reporleorm <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 />FacilityName: CHEVRON 201761 <br />Date of Testing: 02/03/2009 <br />Facility Address: 1103 S. MAIN ST. , MANTECA, CA, 95337 <br />Facility Contact: MGR - MARIE <br />Phone: (2 0 9) 825-0174 <br />Date Local Agency Was Notified of Testing <br />Name of Local Agency Inspector (if present during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: TANKNOLOGY, INC. <br />Technician Conducting Test: STEVEN WILLEMS <br />Credentials : <br />❑ <br />CSLB Contractor ❑ ICC Service Tech. ❑ SWRCB Tank Tester <br />❑ <br />Other (Specify) <br />License Number: <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: <br />X❑ Hydrostatic Vacuum <br />❑ Other <br />Test Equipment Used: tape measure <br />Equipment Resolution: no leak loss <br />Identify Spill Bucket(By Tank <br />Number, Stored Product, etc) <br />I 1 REG FILL 2 2 REG FILL <br />3 3 SUP FILL 4 <br />Bucket Installation Type: <br />Direct Bury Direct Bury <br />X� Contained in Sumpx❑ Contained in SumpXQ <br />0 Direct Bury F-1Direct Bury <br />Contained in Sump ❑ Contained in Sump <br />Bucket Diameter: <br />11 11 <br />11 <br />Bucket Depth: <br />10 10 <br />13 <br />Wait time between applying <br />vacuum/water and starting test: <br />5 mins 5 mins <br />5 mins <br />Test Start Time (TI ): <br />1349 1349 <br />1349 <br />Initial Reading (RI ): <br />9.75 9.75 <br />12 <br />Test End Time (TF ): <br />1449 1449 <br />1449 <br />Final Reading (RF ): <br />9.75 9.75 <br />12 <br />Test Duration. <br />1 hour 1 hour <br />1 hour <br />Change in Reading (R F - RI ): <br />0 0 <br />0 <br />Pass/Fail Threshold or visual visual visual <br />Criteria: <br />Comments - (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />spill buckets contained in sump <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:tJ�J Date: 02/03/2009 <br />I State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements <br />