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SWRCB,January 2006 <br /> 9. Slot Bucket 'Testing Reporleorm <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 ownerloperator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: 7-ELEVEN #14117, MKT 2368 1 DateofTesting: 04/18/2008 <br /> Facility Address: 2725 COUNTRY CLUB BLVD , STOCKTON, CA, 95204 <br /> Facility Contact: MANAGER - G I L 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 /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: RHOME DESBIENS <br /> Credentials 1: []CSLB Contractor [X]ICC Service Tech. SWRCB Tank Tester E Other(Specify) <br /> License Number: <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: Hydrostatic El 'Vacuum � Other <br /> Test Equipment Used:vacuum donut: on reg, and test water on Equipment Resolution: <br /> Identify Spill Bucket'By Tank 1 2 REG FILL <br /> 2 1 PRE FILL 3 4 <br /> Number,Stored Product, etc.) <br /> QX Direct Bury XQ Direct Bury Q Direct Bury ❑Direct Bury <br /> Bucket Installation Type: Contained in Sump ❑ Contained in Sump ❑Contained in Sump Q Contained in Sump <br /> Bucket Diameter: 11 11 <br /> Bucket Depth: <br /> Wait time between applying <br /> vacuum/water and starting test: <br /> Test Start Time(VF <br /> 5 1046 <br /> Initial Reading(R -3011 12 1/211 <br /> Test End Time(T6 <br /> Final Reading{R <br /> " <br /> Test Duration: �n <br /> Change in ReadiPass/Fail Thresh <br /> Criteria: <br /> Test Result: LIKI <br /> Pass El Fail E Pass Fail Pass Fail Pass Fail <br /> Comments - (include information on repairs Inalle 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: 04/18/2008 <br /> State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements <br />