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SWRCB,January 2006 <br /> 9. SWil Bucket Testing Repo 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: SHELL CC # 136187 Date of Testing: 06/10/2009 <br /> Facility Address: 2375 WEST GRANT LINE ROAD , TRACY, CA, 95376 <br /> Facility Contact: MANAGER Phone: (2 0 9) 836-8908 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: STEVEN WILLEMS <br /> Credentials i: CSLB Contractor []ICC Service Tech. ❑SWRCB Tank TesterOther(Specify) <br /> License Number: <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ❑X Hydrostatic ❑ Vacuum 0 Other <br /> Test Equipment Used: tape measure Equipment Resolution:no leak loss <br /> Identify Spill Bucket(By Tank 1 1 REG FILL 2 1 REG VAPOR 3 2 PLU FILL 4 2 PLU VAPOR <br /> Number, Stored Product, etc) <br /> Bucket Installation Type: Direct Bury ®Direct Bury Ej Direct Bury F-�Direct Bury <br /> QX Contained in Sump X-1 Contained in SumpXQ Contained in Sump QX Contained in Sump <br /> Bucket Diameter: 12 12 12 12 <br /> Bucket Depth: 13 14 13.25 12 <br /> Wait time between applying 5 mins 5 mins 5 mins 5 mins <br /> vacuum/water and starting test: <br /> Test Start Time(TI ): 1353 1510 1353 1510 <br /> Initial Reading(RI ): 12.75 13.75 13 11.75 <br /> Test End Time(TF ): 1453 1610 1453 1610 <br /> Final Reading(RF ): 12.75 13.75 13 11.75 <br /> Test Duration: 1 hour 1 hour 1 hour 1 hour <br /> Change in Reading(R F-RI ): 0 0 0 0 <br /> Pass/Fail Threshold or visual visual visual visual <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: <br /> c-7100- U .l ha4. Date: 06/10/2009 <br /> I State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements <br />