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SWRCB,January 2006 <br /> 9. SjjF Bucket Testing Reporeorm <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 (N-621-1-3) Date of Testing: 01/12/2011 <br /> Facility Address: 6633 PACIFIC AVE , STOCKTON, CA, 95207 <br /> Facility Contact: MGR - SUE LYNN Phone: (2 0 9) 477-42 94 <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: JARROD COOKE <br /> Credentials): a CSLB Contractor El ICC Service Tech. ❑SWRCB Tank Tester E Other(Specify) a <br /> License Number: 743160 <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 3 UNL FILL 4 <br /> Number,Stored Product, etc) <br /> ❑Direct Bury E]Direct Bury ❑Direct Bury ❑Direct Bury <br /> Bucket Installation Type: <br /> ❑X Contained in Sump X❑Contained in Sump ®Contained in Sump ❑Contained in Sump <br /> Bucket Diameter: 1211 1211 1211 <br /> Bucket Depth: 1 14.511 14.511 14.511 <br /> Wait time between applying 5min 5min 5min <br /> vacuum/water and starting test: <br /> Test Start Time(TI ): 13:38 13:3 8 13:38 <br /> Initial Reading(RI ): 14.511 13.511 13.511 <br /> Test End Time(TF ): 14 :3 8 14:3 8 14:3 8 <br /> Final Reading(R F ): 14.511 13.511 13.511 <br /> Test Duration: lhr lhr lhr <br /> Change in Reading(R F-RI ): 0 0 0 <br /> Pass/Fail Threshold or 0 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: P-�� Date: 01/12/2011 <br /> I State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements <br />