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SWRCB, January 2006 <br />t SIDI BucketReportWorm <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 />FacilityName: CHEVRON #208117 <br />Date of Testing: 04/01/2008 <br />Facility Address: 755 S. TRACY BLVD TRACY, CA, 95376 <br />Facility Contact: MGR - MARIA <br />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: SCOTT HOLMAN <br />Credentials I : <br />❑ <br />CSLB Contractor [] <br />ICC Service Tech. Ej SWRCB Tank Tester 0 Other (Specify) <br />License Number: <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: <br />Hydrostatic El Vacuum ❑ Other <br />Test Equipment Used: DONUT <br />Equipment Resolution: <br />Identify Spill Bucket(By Tank <br />1 1 SUP FILL <br />2 2 UNL FILL 3 4 <br />Number, Stored Product, etc) <br />® Direct Bury <br />F]Direct Bury ❑ Direct Bury E]Direct Bury <br />Bucket Installation Type: <br />® Contained in Sump <br />® Contained in Sump ® Contained in Sump ❑ Contained in Sump <br />Bucket Diameter: <br />12 <br />12 <br />Bucket Depth: <br />14 <br />14 <br />Wait time between applying <br />IM <br />IM <br />vacuum/water and starting test: <br />Test Start Time (TI ): <br />9:20 <br />9:40 <br />Initial Reading (RI ): <br />-30" <br />-30" <br />Test End Time (TF ): <br />9:21 <br />9:41 <br />Final Reading (RF ): <br />-29" <br />-30" <br />Test Duration: <br />IM <br />IM <br />Change in Reading (R F - RI ): <br />lit <br />0 <br />Pass/Fail Threshold or <br />- 2611 <br />-26" <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 />.� <br />MDate: 04/01/2008 <br />I State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements <br />