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SWRCB,January 2006 <br /> 9. Sp41 Bucket Testing Reportarm <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: 7-ELEVEN #14117, MKT 2368 Date of Testing: 02/24/2011 <br /> Facility Address: 2725 COUNTRY CLUB BLVD STOCKTON, CA, 95204 <br /> Facility Contact: MANAGER - GIL Phone: (2 0 9) 463-1259 <br /> Date Local Agency Was Notified of Testing: / f <br /> Name of Local Agency Inspector(if present during testing): Stacy Rivera,Rexs <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: LTULIAN TILLMAN <br /> Credentials : a CSLB Contractor E ICC Service Tech. 1:1SWRCB Tank Tester Other(Sped) contractors <br /> License Number: 743160 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ❑ Hydrostatic El Vacurun ❑ Other <br /> Test Equipment Used: tape measure Equipment Resolution:1/16 <br /> Identify Spill Bucket(By Tank 1 PRE FILL 2 2 REG FILL 3 4 <br /> Number, Stored Product, etc.) <br /> M Direct Bury ®Direct Bury ❑i Direct Bury ®Direct Bury <br /> Bucket Installation Type: <br /> ❑ Contained in Sump ❑ Contained in Sump ❑Contained in Suinp ❑ Contained in Sump <br /> Bucket Diameter: 1110 1111 <br /> Bucket Depth: 1511 1411 <br /> Wait time between applying 5 see 5 sec <br /> vacuum/water and starting test: <br /> Test Start Time(TI j: 9:00 9:05 <br /> Initial Reading(Rt }: 30 30 <br /> Test End Time(TF ): 9:01 9:0 6 <br /> Final Reading(R F }: 26 28 <br /> Test Duration: 1. min 1 min. <br /> Change in Reading(R F-R1 ): <br /> 4 2 <br /> Pass/Fail Threshold or 4 <br /> Criteria: <br /> Test Result: 1fl Pass ❑ Fail 1XI PassE] Fail ❑Pass ❑ Fail ❑Pass [❑ Fail <br /> COmmentS - (include information on repairs made prior to testing, and recornmended follow-up for failed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> 1 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: 02/24/2011 <br /> t State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements <br />