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SWRCB,January 2006 <br /> 9. S0111 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 /> FacilityName: CHEVRON 209167 Date of Testing: 04/08/2008 <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): NO SHOW <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(Specify) <br /> License Number: 5297793-UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: [K] Hydrostatic 0 Vacuum El Other <br /> Test Equipment Used:TAPE MEASURE Equipment Resolution:NO VISABLE LOSS <br /> Identify Spill Bucket(By Tank 1 1 SUP FILL Z 2 UNL FILL 3 4 <br /> Number,Stored Product, etc) <br /> Bucket Installation Type: �X Direct Bury X❑Direct Bury ❑Direct Bury Ej Direct Bury <br /> ❑Contained in Sump ❑Contained in Sump ❑Contained in Sump ❑Contained in Sump <br /> Bucket Diameter: 1411 1411 <br /> Bucket Depth: 1411 1419 <br /> Wait time between applying 1 MIN 1 MIN <br /> vacuum/water and starting test: <br /> Test Start Time(TI ): 16:40 16:4 0 <br /> Initial Reading(R I ): 1411 13 5/811 <br /> Test End Time(TF ): 17:40 17:40 <br /> Final Reading(RF ): 1411 13 5/811 <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: .1-21) ��`� 1� Date: 04/08/2008 <br /> I State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements <br />