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SWRCB,January 2006 <br /> 9. Spe 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(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 DateofTesting: 06/21/2010 <br /> Facility Address: 4943 S. KINGSLEY (FRONTAGE RD) HWY 99 @ 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): THUY TRAM <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: MICHAEL STRANGE <br /> Credentialsl: E]CSLB Contractor E]ICC Service Tech. E:]SWRCB Tank Tester ❑Other(Specify) <br /> License Number: <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: 0 Hydrostatic Vacuum 1:1 Other <br /> Test Equipment Used:WATER AND MEASURE TAPE Equipment Resolution:1/8 <br /> Identify Spill Bucket(By Tank I 4 REG FILL Z 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: <br /> X❑Contained in SumpX❑ Contained in Sump Contained in Sump ❑Contained in Sump <br /> Bucket Diameter: 11 11 11 <br /> Bucket Depth: 17 17 18 <br /> Wait time between applying 1MIN 1MIN 1MIN <br /> vacuum/water and starting test: <br /> Test Start Time(TI ): 1220 1150 1020 <br /> Initial Reading(RI ): 16 3/4 16 3/4 17 1/2 <br /> Test End Time(TF ): 1320 1250 1120 <br /> Final Reading(R F ): 16 3/4 16 3/4 17 1/2 <br /> Test Duration: 1 HR 1 HR 1 HR <br /> Change in Reading(R F-RI ): 0 0 0 <br /> Pass/Fail Threshold or 0 0 0 <br /> Criteria: <br /> Fest Result: Pass 1:1 Fail Pass ❑ Fail Pass 1:1 Fail Pass Fail <br /> Comments- (include information on repairs made 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 <br /> diin_this report is true,accurate,and in full compliance with legal requirements. <br /> Technicians Signature: �*��\�kin """�'� Date: 06/21/2010 <br /> t State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements <br />