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SWRCB,January 2006 <br /> 9. Slfl 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 /> 1. FACILITY INFORMATION <br /> Facility Name: CHEVRON # 96171 Date of Testing: 02/09/2 009 <br /> Facility Address: 6633 PACIFIC AVE @ BENJAMIN HOLT DR. , STOCKTON, CA, 95204 <br /> Facility Contact: MGR - SUE LYNN Phone: (2 0 9) 477-4115 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): GARRETT BACKUS <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: KENNETH LEE <br /> Credentials : E1 CSLB Contractor ❑x ICC Service Tech ❑SWRCB Tank Tester E Other(Specify)VEETEROOT <br /> License Number: B 3 613 0 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ❑X Hydrostatic ❑ Vacuum ❑ Other <br /> Test Equipment Used:TAPE MEASURE Equipment Resolution:VISUAL <br /> Identify Spill Bucket(By Tank 1 2 UNL FILL 2 3 UNL FILL 3 1 SUP FILL 4 <br /> Number, Stored Product, etc) <br /> Bucket Installation Type: F-1Direct Bury ❑Direct Bury ❑Direct Bury ❑Direct Bury <br /> ❑x Contained in Sumpx❑Contained in SumpX❑Contained in Sump ❑Contained in Sump <br /> Bucket Diameter: 12 ' ' 12 ' ' 12 ' ' <br /> Bucket Depth: 15 1 1 15 1 1 151 ' <br /> Wait time between applying 5MIN 5MIN 5MIN <br /> vacuum/water and starting test: <br /> Test Start Time(TI ): 9:11 9:11 9:10 <br /> Initial Reading(RI ): 133/811 13 ' ' 131/81 ' <br /> Test End Time(TF ): 10:11 10:11 10:10 <br /> Final Reading(RF ): 133/81 ' 13 ' ' 131/8- ' <br /> Test Duration: 6 0M IN 6 0 MIN 6 0M IN <br /> Change in Reading(R F-RI ): <br /> 0' ' 0' ' 0' i <br /> Pass/Fail Threshold or Oil oil 0' ' <br /> Criteria: <br /> Comments - (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> ALL BUCKETS TESTED PASSED <br /> CERTIFICATION OF TECE NICIAN 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 requirement& <br /> Technician's Signature: 4 / Date: 02/09/2009 <br /> I State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements <br />