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' <br /> 9. S011 bucket Testing epor or SWRCB,January 2006 <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 Date of Testing: 0 5/2 8/2 010 <br /> Facility Address: 2375 WEST GRANT LINE ROAD N-1094-1-5, TRACY, CA, 95376 <br /> Facility Contact: MANAGER 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): a CSLB Contractor a ICC Service Tech. ❑SWRCB Tank Tester E Other(Spec) CONTRACTOR <br /> License Number: 743160 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: El Hydrostatic ❑ Vacuum ❑ Other <br /> Test Equipment Used: Equipment Resolution: <br /> Identify Spill Bucke�By Tank 1 3 PRE FILL Z 3 PRE VAPOR 3 4 DIE FILL 4 <br /> Number, Stored Product, etc.) <br /> ® <br /> Bucket Installation Type: Direct Bury Direct Bury ®Direct Bury ❑Direct Bury <br /> ❑X Contained in Sump XQ Contained in SumpX❑Contained in Sump ❑ Contained in Sump <br /> Bucket Diameter: 12 12 12 <br /> Bucket Depth: 13 15 13 <br /> Wait time between applying 5MIN 5MIN 5MIN <br /> vacuum/water and starting test: <br /> Test Start Time(TI ): 1030 1030 1140 <br /> Initial Reading(RI ): 12.5 14.5 12 <br /> Test End Time(TF ): 1130 1130 1240 <br /> Final Reading(RF ): 12.5 14 .5 12 <br /> Test Duration: 1HR 1HR 1HR <br /> Change in Reading(R F -RI ): 0 0 0 <br /> Pass/Fail Threshold or 0 0 0 <br /> Criteria: <br /> r c i <br /> ,00 n� <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 /> ICa..ao 1.,..... .,.,,7 ....,,a«.,..a.,« U....,.-- /.,...,1 <br />