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` SWRCB,January 2006 <br /> 9. SIDI Bucket Testing Repor0orm <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(f applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> FacilityName: SHELL CC # 136187 DateofTesting: 05/28/2010 <br /> Facility Address: 2375 WEST GRANT LINE ROAD N-1094-1-5, TRACY, CA, 95376 <br /> Facility Contact: MANAGER I Phone: (2 0 9) 836-8908 <br /> Date Local Agency Was Notified of Testing : 05/12/2010 <br /> Name of Local Agency Inspector(if present during testing): STACY <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: KELVIN CRUZ <br /> Credentials): X❑CSLB Contractor E ICC Service Tech. ❑SWRCB Tank Tester ElOther(Specify) CONTRACTOR <br /> License Number: 7 4 316 0 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: Hydrostatic Vacuum ❑ Other <br /> Test Equipment Used: Equipment Resolution: <br /> Identify Spill Bucke�By Tank 1 1 REG FILL 2 1 REG VAPOR 3 2 PLU FILL 4 2 PLU VAPOR <br /> Number, Stored Product, etc.) <br /> [�Direct Bury Direct Bury Direct Bury Direct Bury <br /> Bucket Installation Type: Q Contained in Sump X❑ Contained in SumpX❑Contained in SumpXQ Contained in Sump <br /> Bucket Diameter: 12 12 12 12 <br /> Bucket Depth: 14 15 13 14 <br /> Wait time between applying 5MIN 5MIN 5MIN 5MIN <br /> vacuum/water and starting test: <br /> Test Start Time(TI ): 1030 1030 1030 1030 <br /> Initial Reading(RI ): 13.5 15 12.5 13.5 <br /> Test End Time(TF ): 1130 1130 1130 1130 <br /> Final Reading(RF ): 13.5 15 12.5 13.5 <br /> Test Duration. 1HR 1HR 1HR 1HR <br /> Change in Reading(R F -RI ): 0 0 0 0 <br /> Pass/Fail Threshold or 0 0 0 0 <br /> Criteria: <br /> L,Jao <br /> ,g �: .,rh<r'�$ a"' & <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: Date: 05/28/2010 <br /> IQ+.+.1.,.,... .,.,4«e,.,.l.,r:.,.,,. .i...,..�...,....o.,rl..«o,.,.:«o+o..r:,,..r.,i,o..e«F;,...,.o.i 1+.,o .,,,.,I:F:o.l .....,r...,..r..« T.T.........« 1.....,1 <br />