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SWRCB,January 2006 <br /> 9. 11 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 209167 Date of Testing: 03/20/2009 <br /> Facility Address: 1234 E. YOSEMITE AVE @ SPRECKLES, MANTECA, CA, 95336 <br /> Facility Contact: MANAGER - KIM Phone: (2 0 9) 824-7433 <br /> Date Local Agency Was Notified of Testing <br /> Name of Local Agency Inspector(if present during testing): GARETT <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: KRISTOPHER BELL <br /> Credentials I: ❑CSLB Contractor E ICC Service Tech. ❑SWRCB Tank Tester []Other(Spec) <br /> License Number: 5297793-UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ❑X Hydrostatic ❑ Vacuum ❑ Other <br /> Test Equipment Used:TAPE MEASURE Equipment Resolution:NO VISABLE LOSS <br /> Identify Spill Bucket(By Tank 1 1 SUP FILL 2 2 UNL FILL 3 1 SUP FILL 4 <br /> Number, Stored Product, etc) <br /> Bucket Installation Type: XQ Direct Bury X❑Direct Bury X❑Direct Bury Direct Bury <br /> ❑Contained in Sump ❑Contained in Sump ❑Contained in Sump ❑ Contained in Sump <br /> Bucket Diameter: <br /> 1411 1411 1411 <br /> Bucket Depth: 1511 1511 1511 <br /> Wait time between applying 1 MIN 1 MIN 1 MIN <br /> vacuum/water and starting test: <br /> Test Start Time(TI ): 12 :17 8:59 8:59 <br /> Initial Reading(RI ): 14 1/211 14" 14 1/211 <br /> Test End Time(TF ): 13 :17 9:59 9:59 <br /> Final Reading(RF ): 14 1/211 14 " 1411 <br /> Test Duration: 1 HR 1 HR 1 HR <br /> Change in Reading(R F-RI ): <br /> 0" 0" 1/2" <br /> Pass/Fail Threshold or 0" 01, 0" <br /> Criteria: <br /> MEMEMESEEMEMEMEW <br /> Comments - (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> REPAIRED THE 91 SPILL BUCKET AS IT ORIGINALLY FAILED. REMOVED AND CLEANED THE DRAIN. <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: -R �c-�`—"`-" Date: 03/20/2009 <br /> I State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements <br />