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SWRCB, January 2006 <br />9. S11 Bucket Testing Repor i orm <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 />FacilityName: TOYS "R" US <br />Date of Testing: 09/07/2007 <br />Facility Address: 1624 ARMY CT , STOCKTON, CA, 95297 <br />Facility Contact: MANAGER <br />Phone: (2 0 9) 465-4912 <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (if present during testing): RAY VON FLUE <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: TANKNOLOGY , INC. <br />Technician Conducting Test: DOUGLAS HARTY <br />Credentialsi : <br />❑ <br />CSLB Contractor <br />[fl <br />ICC Service Tech. <br />❑ <br />SWRCB Tank Tester <br />1fl <br />Other (Specify) SERVICE TECH <br />License Number: 5244407 -UT <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: ❑ Hydrostatic Vacuum ❑ Other <br />Test Equipment Used: VAC TESTER <br />Equipment Resolution: IN WC <br />Identify Spill Bucket(By Tank <br />Number, Stored Product, etc) <br />1 1 DIE FILL <br />2 <br />3 <br />4 <br />Bucket Installation Type: <br />❑X Direct Bury <br />❑ Contained in Sump <br />E]Direct Bury <br />❑ Contained in Sump <br />❑ Direct Bury <br />❑ Contained in Sump <br />❑ Direct Bury <br />❑ Contained in Sump <br />Bucket Diameter: <br />12 <br />Bucket Depth: <br />12 <br />Wait time between applying <br />vacuum/water and starting test: <br />1 MIN <br />Test Start Time (TI ): <br />12 : 0 9 <br />Initial Reading (RI ): <br />30 <br />Test End Time (TF ): <br />12:10 <br />Final Reading (RF ): <br />30 <br />Test Duration: <br />1 M I N <br />Change in Reading (R F - RI ): <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />4 " WC <br />Test Result, <br />[fl Pass El Fail <br />E]Pass 0 Fail <br />E] Pass E] Fail <br />Pass E] Fail <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: <br />09/07/2007 <br />1 State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements <br />