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9. S$k1 Bucket Testing Report orm SWRCB,January 2006 <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(ifapplicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> FacilityName: 7-ELEVEN #32190, MKT 2368 1 Dateof Testing: 06/07/2011 <br /> Facility Address: 4943 S. KINGSLEY (FRONTAGE RD) HWY 99 O ARCH AIRPORT RD, STOCKTON, CA, <br /> Facility Contact: MGR - LORENA Phone: (209) 939-0679 <br /> Date Local Agency Was Notified of Testing <br /> Name of Local Agency Inspector(if present during testing): Michelle H <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: STEVEN WILLEMS <br /> Credentials t: E CSLB Contractor ff]ICC Service Tech. 1:1 SWRCB Tank Tester E Other(Specify) icc <br /> License Number. 8016974 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ❑X Hydrostatic ❑ Vacuum ❑ Other <br /> Test Equipment Used: tape measure Equipment Resolution:0 loss <br /> Identify Spill Bucket(By Tank t 4 REG FILL r 5 MID FILL 3 6 PRE FILL 4 <br /> Number, Stored Product, etc.) <br /> ❑Direct Bury ❑Direct Bury ❑Direct Bury ❑Direct Bury <br /> Bucket Installation Type: X❑ Contained in Sum X Contained in Sum X Contained in Sum p ❑ p ❑ p ❑ Contained in Sump <br /> Bucket Diameter: 121- 12" 12-1 <br /> Bucket Depth: 15.5" 16" 17" <br /> Wait time between applying 5 mins 5 mins 5 mins <br /> vacuum/water and starting test: <br /> Test Start Time(TI ): 9:20 9:20 9:20 <br /> Initial Reading(RI ): 15.5" 16" 17-- <br /> Test <br /> 7"Test End Time(TF ): 10:2 0 10:20 10:2 0 <br /> Final Reading(RF ): 15.5" 16" 17" <br /> Test Duration: 1 hour 1 hour 1 hour <br /> Change in Reading(R F-Ri ): 0 0 0 <br /> Pass/Fail Threshold or 0 loss 0 loss 0 loss <br /> Criteria: <br /> Test Result: Pass ❑ Fail l Pass ❑ Fail X❑Pass 0 Fail 1:1 Fail <br /> Comments - (include information on repairs made prior to testing, and recommended follow-up forfailed 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 /> C--g(y.,., l�1 , <br /> Technician's Signature: , JtXl'w Date: 06/07/2011 <br /> t State laws and regulations do not currently require testing to be performed by a qualified contractor. However,local requirements <br />