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SWRCB,January 2006 <br /> 9. S0111 Bucket Testing RepAlForm <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 /> 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 Tester [:]Other(Specify) <br /> License Number: <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: E Hydrostatic ❑ Vacuum ❑ Other <br /> Test Equipment Used: tape measure Equipment Resolution:no leak loss <br /> Identify Spill Bucket(By Tank 1 3 PRE FILL 2 3 PRE VAPOR 3 4 DIE FILL 4 <br /> Number,Stored Product, etc) <br /> ❑Direct Bury ❑Direct Bury ❑Direct Bury Direct Bury <br /> Bucket Installation Type: ❑Contained in Sump ®Contained in Sump X❑Contained in Sump ❑Contained in Sump <br /> Bucket Diameter: 12 12 12 <br /> Bucket Depth: 13 14 11.75 <br /> Wait time between applying 5 mins 5 mins 5 mins <br /> vacuum/water and starting test: <br /> Test Start Time(TI ): 1353 1510 1353 <br /> Initial Reading(RI ): 12.5 13.75 11.75 <br /> Test End Time(TF ): 1453 1610 1453 <br /> Final Reading(RF ): 12.5 13 .75 11.75 <br /> Test Duration: 1 hour 1 hour 1 hour <br /> Change in Reading(R F-RI ): 0 0 0 <br /> Pass/Fail Threshold or 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: 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 />