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SwKuB,JanuaryLt1VU <br /> 9. SISI Bucket Testing Reporlo 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 ovwnerloperatorfor submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: 7-ELEVEN #14117, MKT 2368 Date of Testing: 04/02/2009 <br /> Facility Address: 2725 COUNTRY CLUB BLVD STOCKTON, CA, 95204 <br /> Facility Contact: MANAGER - GIL Phone: (209) 463-1259 <br /> Date Local Agency Was Notified of Testing: / / <br /> Name of Local Agency Inspector(if present during testing): RAY VON FLUE RENS <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC <br /> Technician Conducting Test: JOEY MESA <br /> Credentials': ❑CSLB Contractor E ICC Service Tech. ❑SWRCB Tank Tester E Other(Specify) ICC SERVICE <br /> License Number: 5259458-UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: Q Hydrostatic ❑ Vacuum ❑ Other <br /> Test Equipment Used:TAPE MEASURE Equipment Resolution:VISUAL LOSS <br /> Identify'Spill Bucket(By Tank 1 I PRE FILL Z 2 REG FILL 3 4 <br /> Number, Stored Product, etc.) <br /> ®Direct Bury 0 Direct Bury Q Direct Bury ❑Direct Bury <br /> Bucket Installation Type: <br /> ❑Contained in Sump ❑ Contained in Sump ❑Contained in Sump Contained in Sump <br /> Bucket Diameter: <br /> 11" 11" <br /> Bucket Depth: japplying <br /> 14 1/411 14 1/411 <br /> Wait time between 5 MIN. 5 MIN. <br /> vacuum/water and Test Start Time(T10-50 9:3 6 <br /> Initial Reading(RI ): 12. 5/811 12 5/811 <br /> Test End Time(TF ): 11:50 10:3 6 <br /> Final Reading(RF ): <br /> 12 5/81 ' 12 5/8" <br /> Test Duration: 60 MIN. 60 MIN. <br /> Change in Reading(R F-RI ): <br /> Oil Oil <br /> Pass/Fail Threshold or VISUAL LOSS VISUAL LOSS <br /> Criteria: <br /> Test Result: ElPass ❑ Fail ❑ Pass 1:1Fail ❑Pass ❑ Fail LlPass ❑ Fail <br /> Comments - (include information on repairs made prior to testing, and recotnmei)d(,d folloi-v-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: lvv Date: 04/02/2009 <br /> el- <br /> State laws and regulations do not currently require testing to be performed by a qualified contractor.However, local requirements <br />