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SWRCB,January 2006 <br /> 9. S&I Bucket Testing Repor*orm <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 /> I. FACILITY INFORMATION <br /> Facility Name: 7-ELEVEN ##32190 (N-3810) , MKT 2237 1 Date of Testing: 01/08/2008 <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): GARRET RENS <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: JOEY MESA. <br /> Credentials t: ❑CSLB Contractor E ICC Service Tech. ❑SWRCB Tank Tester E Other(Specify) ICC SERVICE <br /> License Number: 5259458-UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: El Hydrostatic ❑ Vacuum ❑ Other <br /> Test Equipment Used: TAPE MEASURE Equipment Resolution:VISUAL LOSS <br /> Identify Spill Bucket(py Tank t 3 PRE FILL Z 4 REG FILL 3 5 MIO FILL 4 <br /> Number, Stored Product, etc.) <br /> ❑Direct Bury L]Direct Bury ❑Direct Bury ❑Direct Bury <br /> Bucket Installation Type: Q Contained in.Sump Q Contained in Sump ®Contained in Sump 0 Contained in Sump <br /> Bucket Diameter: <br /> Bucket Depth: 1511 15 It 15" <br /> Wait time between applying 5 MIN. 5 MIN. 5 MIN. <br /> vacuum/water and starting test: <br /> Test Start Time(Tj }: 12 :15 12 :15 12 :15 <br /> Initial Reading(Rt }: 1411 1411 14-11 <br /> Test End Time(TF }: 13 :2 0 13 :20 13 :2 0 <br /> Final Reading(R F }: 1411 1411 1411 <br /> Test Duration: 60 MIN. 60 MIN. 60 MIN. <br /> n <br /> Change in Reading(R F - R i ): VTI Oil O 11 <br /> Pass/Fail Threshold or VISUAL LOSS VISUAL LOSS VISUAL LOSS <br /> Criteria: <br /> Test Result: Pass ❑ Fail [i]Pass 0 Fail 0 Pass ❑ Fail ❑ Pass ❑ Fail <br /> Cornments - (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> CERTIFICATION OF TECIINICIAN 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: 11t - Date: 01/08/2008 <br /> t State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements <br />