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SWRCB,January 2006 <br /> 9. S191 Bucket Testing Reporoorm <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: 03/06/2009 <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): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: EDWIN BUECHLER <br /> Credentials : ❑CSLB Contractor []ICC Service Tech. E]SWRCB Tank Tester []Other(Specify) <br /> License Number: <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: El Hydrostatic El Vacuum 0 Other <br /> Test Equipment Used: 11 Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1 1 SUP FILL 2 1 SUP VAPOR 3 2 UNL FILL 4 2 UNL VAPOR <br /> Number, Stored Product, etc) <br /> El Direct Bury Direct Bury ❑Direct Bury E]Direct Bury <br /> Bucket Installation Type: ®Contained in Sump ® Contained in Sump ® Contained in Sump ® Contained in Sump <br /> Bucket Diameter: 12 12 12 12 <br /> Bucket Depth: 14 14 14 14 <br /> Wait time between applying 5min 5min 5min 5min <br /> vacuum/water and starting test: <br /> Test Start Time(TI ): 9:20A 9:20A 9:20A 9:2OA <br /> Initial Reading(R I ): 12.5 12 1/8 12 1/8 12.2 5 <br /> Test End Time(TF ): 10:20A 10:20A 10:20A 10:20A <br /> Final Reading(R F ): 12.5 12 1/8 12 1/8 12.2 5 <br /> Test Duration: lhr lhr lhr lhr <br /> Change in Reading(R F-RI ): 0 0 0 0 <br /> Pass/Fail Threshold or 0 0 0 0 <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: 1� Date: 03/06/2009 <br /> I State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements <br />