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SWRCB,January 2006 <br /> 9. SI&I Bucket Testing Reporoorm <br /> This form is intended for use by contractors perforating 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: 7-ELEVEN #14117, MILT 2368 1 DateofTesting: 05/19/2008 <br /> Facility Address: 2725 COUNTRY CLUB BLVD STOCKTON, CA, 95204 <br /> Facility Contact: MANAGER - G IL Phone: (2 0 9) 463-1259 <br /> Date Local Agency Was Notified of Testing: / / <br /> Name of Local Agency Inspector(if present during testing): <br /> z. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: JARROD COOKS <br /> Credentials I: ❑CSLB Contractor ❑ICC Service Tech. ❑SWRCB Tank Tester ❑Other(Specify) <br /> License Number: <br /> 3, SPILL BUCKET TESTING INFORMATION <br /> F <br /> ethod Used: � Hydrostatic ElVacuum Other <br /> quipment Used: Equipment Resolution:. <br /> 3 4 <br /> Identify Spill Bucket'By Tank 1 2 PRE FILL 2 <br /> Number, Stored Product, etc.) <br /> Direct Bury ❑Direct Bury ❑Direct Bury ❑Direct Bury <br /> Bucket Installation Type: ❑ Contained in Sump ❑ Contained in Sump ❑Contained in Sump ❑ Contained in Sump <br /> Bucket Diameter: <br /> 13° <br /> Bucket Depth: <br /> 11" <br /> Wait time between applying 5min <br /> vacuum/water and starting test: <br /> Test Start Time(TI ): 6:36 <br /> Initial Reading(Ri ): 911 <br /> Test End Time T 9:36 <br /> Final Reading(RF ): <br /> 9" - <br /> Test Duration: 1hr <br /> Change in Reading(R F-RI ): 0 <br /> Pass/Fail Threshold or 0 <br /> Criteria: <br /> Test Result: Pass ElFail ElPass ❑ Fail ❑Pass ❑ Fail ❑Pass ❑ Fail <br /> Comments - (include information on rcp(rir-.� nttule 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 /> Date: 05/19/2008 <br /> Technician's Signature T <br /> I State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements <br />