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SWRCB,January 2006 <br /> i 9. 11 Bucket Testing Repolworm <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 #208117 Date of Testing: 02/16/2010 <br /> Facility Address: 755 S. TRACY BLVD TRACY, CA, 95376 <br /> Facility Contact: MGR - MARIA Phone: (2 0 9) 830-0370 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): MICHELLE HENRY <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: DANIEL ROLLINS <br /> Credentials 1: ❑CSLB Contractor ❑X ICC Service Tech. 0 SWRCB Tank Tester ❑x Other(Specify) ICC <br /> License Number: 8011610 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: El Hydrostatic ❑ Vacuum ❑ Other <br /> Test Equipment Used:TEST WATER Equipment Resolution:l/8" <br /> Identify Spill Bucket(By Tank 1 1 SUP FILL 2 2 UNL FILL 3 4 <br /> Number,Stored Product, etc) <br /> ❑Direct Bury ❑Direct Bury F-1Direct Bury ❑Direct Bury <br /> Bucket Installation Type: <br /> ®Contained in Sump ®Contained in Sump ❑Contained in Sump ❑Contained in Sump <br /> Bucket Diameter: 11 11 <br /> Bucket Depth: 13 1/2 13 1/2 <br /> Wait time between applying 5 MIN 5 MIN <br /> vacuum/water and starting test: <br /> Test Start Time(TI ): 1210 1210 <br /> Initial Reading(RI ): 13 1/2 13 1/2 <br /> Test End Time(TF ): 1310 1310 <br /> Final Reading(RF ): 13 1/2 13 1/2 <br /> Test Duration: 1 HR 1 HR <br /> Change in Reading(R F-RI ): 0 0 <br /> Pass/Fail Threshold or 0 0 <br /> Criteria: <br /> mm............ .................. <br /> Comments - (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> CERTIFICATION OF TEC>FINICIAN 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: i2 l Date: 02/16/2010 <br /> I State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements <br />