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SWRCB, January 2006 <br />9. Sf Bucket Testing Report )rm <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: QUICK STUFF #7789 <br />Date of Testing: 11/13/2007 <br />Facility Address: 10858 TRINITY PKWY , STOCKTON, CA, 95210 <br />Facility Contact: MGR - DAVID COOPER <br />Phone: (209) 952-2213 <br />Date Local Agency Was Notified of Testing: / / <br />Name of Local Agency Inspector (if present during testing): GARRETT BACKUS <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: TANKNOLOGY, INC. <br />Technician Conducting Test: KELVIN CRUZ <br />Credentialsi : <br />❑ <br />CSLB Contractor <br />❑X ICC Service Tech. <br />❑ <br />SWRCB Tank Tester <br />E <br />Other (Spec) SPILL BKT <br />License Number: 5254041 -UT <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: ❑ Hydrostatic ❑X Vacuum 0 Other <br />Test Equipment Used: DONUT <br />Equipment Resolution: <br />Identify Spill Bucket(By Tank <br />Number, Stored Product, etc) <br />1 1 UNL FILL <br />2 2 PRE FILL <br />3 3 DIE FILL <br />4 <br />Bucket Installation Type: <br />❑ Direct Bury <br />❑X Contained in SumpX❑ <br />❑ Direct Bury <br />Contained in Sump <br />❑ Direct Bury <br />❑X Contained in Sump <br />❑ Direct Bury <br />❑ Contained in Sump <br />Bucket Diameter: <br />10 <br />10 <br />10 <br />Bucket Depth: <br />12 <br />12 <br />12 <br />Wait time between applying <br />vacuum/water and starting test: <br />1MIN <br />1MIN <br />1MIN <br />Test Start Time (TI ): <br />0920 <br />0925 <br />0928 <br />Initial Reading (RI ): <br />30 <br />30 <br />30 <br />Test End Time (TF ): <br />092 <br />0926 <br />0929 <br />Final Reading (R F ): <br />30 <br />29 <br />30 <br />Test Duration: <br />1MIN <br />1MIN <br />1MIN <br />Change in Reading (R F - R1 ): <br />0 <br />1 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />Test Result: <br />[Z] Pass F—] Fail <br />Pass [:] Fail <br />❑ Pass 0 <br />Fail <br />El Pass <br />ElFail <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: 11/13/2007 <br />I State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements <br />