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SWRCB,January 2006 <br /> 9. S i Bucket Testing eor 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: 03/03/2010 <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): thuy tran <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: JARROD COOKE <br /> Credentials 1: E CSLB Contractor E ICC Service Tech. []SWRCB Tank Tester ❑X Other(Specify) a <br /> License Number: 7 4 316 0 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: Hydrostatic ❑ Vacuum ❑ Other <br /> Test Equipment Used: tape Equipment Resolution:1/16" <br /> Identify Spill Bucket(By Tank 1 1 SUP FILL 2 2 UNL FILL 3 4 <br /> Number, Stored Product, etc) <br /> Bucket Installation Type: QX Direct Bury X]Direct Bury F-1Direct Bury F�Direct Bury <br /> ❑Contained in Sump ❑Contained in Sump ❑Contained in Sump ❑Contained in Sump <br /> Bucket Diameter: 1211 1211 <br /> Bucket Depth: 15.511 15.511 <br /> Wait time between applying 5min 5min <br /> vacuum/water and starting test: <br /> Test Start Time(TI ): 9:12 9:12 <br /> Initial Reading(RI ): <br /> 15" 15" <br /> Test End Time(TF ): 10:12 10-12 <br /> Final Reading(RF ): <br /> 15" 15" <br /> Test Duration: lhr 1hr <br /> Change in Reading(R F-RI ): 0 0 <br /> Pass/Fail Threshold or 0 0 <br /> Criteria: <br /> Comments- (include information on repairs made prior to testing, and recommended follow-up for failed tests) <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: W-�� Date: 03/03/2010 <br /> i State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements <br />