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SWRCB,January 2006 <br /> 9. Spill Bucket Testing Report Form <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 /> Facility Name: CIRCLE K 2701205 DateofTesting: 10/14/2011 <br /> Facility Address: 16470 CAMBRIDGE @ LOUISE, LATHROP, CA, 95330 <br /> Facility Contact: ROBERT- PERMIT (N-206-1-4) Phone: (209) 858-4116 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): THUY <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: TIMOTHY COULTER <br /> Credentials I:❑X CSLB Contractor ❑X ICC Service Tech. ❑SWRCB Tank Tester ❑X Other(Spec)A-UT <br /> License Number: 5295244-734160 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: [y] Hydrostatic Vacuum E Other <br /> Test Equipment Used: TAPE MEASURE Equipment Resolution:VISUAL <br /> Identify Spill Bucket(By Tank 1 UNL FILL 2 2 SUP FILL 3 <br /> Number, Stored Product, etc.) <br /> X❑ <br /> Bucket Installation Type: Direct Bury X❑Direct Bury ❑ Direct Bury ❑ Direct Bury <br /> ❑Contained in Sump ❑ Contained in Sump ❑ Contained in Sump E]Contained in Sump <br /> Bucket Diameter: 10 10 <br /> Bucket Depth: 10 10 <br /> Wait time between applying 10 MINS 10 MINS <br /> vacuum/water and starting test: <br /> Test Start Time(TI ): 1245 1245 <br /> Initial Reading(RI ): 9 9 <br /> Test End Time(TF ) 1345 1345 <br /> Final Reading(RF ): 9 9 <br /> Test Duration: 1 HR 1 HR <br /> Change in Reading(R F-RI ): 0 0 <br /> Pass/Fail Threshold or 0 0 <br /> Criteria: <br /> Test Result: X❑Pass El Fail El Pass ❑ Fail E] Pass E] Fail E:] Pass 0 Fail <br /> Comments - (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 hue,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: 4 ~ Date: 10/14/2011 <br /> State laws and regulations do not currently require testing to be Derformed by a qualified contractor.However,local requirements <br />