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9. 01 Bucket Testing Repoftbrm 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/operatorfor submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: 7-ELEVEN #32190 (N-3810) , MKT 2368 1 DateofTesting: 12/01/2009 <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): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: BRYAN KEYS <br /> Credentialsi: D CSLB Contractor D ICC Service Tech. E SWRCB Tank Tester D Other(Specify) <br /> License Number: 07-17 35 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: [K] Hydrostatic Vacuum D Other <br /> Test Equipment Used:TEST FLUID, TAPE MEASURE Equipment Resolution:VI S UAL LOSS <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 /> ❑ <br /> Bucket Installation Type: Direct Bury ❑ Direct Bury ❑Direct Bury ❑Direct Bury <br /> x❑Contained in Sum X❑ Contained in Sum X❑ Contained in Sump ❑ Contained in Sum <br /> Bucket Diameter: 14 14 14 <br /> Bucket Depth: 14 14 14 <br /> Wait time between applying 1 MIN 1 MIN 1 MIN <br /> vacuum/water and starting test: <br /> Test Start Time(TI ): 1130 1130 1130 <br /> Initial Reading(RI ): 13 13 13 1/4 <br /> Test End Time(TF ): 1230 1230 1230 <br /> Final Reading(RF ): 13 13 13 1/4 <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 /> Test Result: l Pass ❑ Fail [z]Pass ❑ Fail FLI Pass ❑ Fail E]Pass ❑ Fail <br /> Comments - (include information on repairs made prior to testing, and recommended follow-upforfailed 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: /zy^- Date: 12/01/2009 <br /> t State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements <br />