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SWRCB,January 2006 <br /> 9. Sr,..; Bucket Testing Report,'DrIn <br /> This form is intended for use by contractors performing annual testing of UST spill containment structures. The completedform and <br /> printouts from tests(if applicable),should beprovided to the facility owner/operatorfor submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: CIRCLE K 2701205, MKT #2616 (N-206) Dateof Testing: 11/14/2008 <br /> Facility Address: 16470 CAMBRIDGE , LATHROP, CA, 95330 <br /> Facility Contact: MANAGER-ROBERT Phone: (209) 858-4116 <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: RHOME DESBIENS <br /> Credentials 1: ❑CSLB Contractor ❑x ICC Service Tech. ❑SWRCB Tank Tester 1:1 Other(Spec) <br /> License Number: <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ❑ Hydrostatic �x Vacuum F-1 Other <br /> Test Equipment Used:vacuum donut Equipment Resolution: <br /> Identify Spill Bucket(By Tank r 1 UNL FILL 2 2 SUP FILL 3 4 <br /> Number,Stored Product, etc.) <br /> X❑ <br /> Bucket Installation Type: Direct Bury K❑Direct Bury E]Direct Bury ❑Direct Bury <br /> ❑Contained in Sump ❑Contained in Sump ❑Contained in Sump ❑Contained in Sump <br /> Bucket Diameter: 11 11 <br /> Bucket Depth: <br /> Wait time between applying <br /> vacuum/water and starting test: <br /> Test Start Time(TI ): 1205 1210 <br /> Initial Reading(RI ): -30" -30" <br /> Test End Time(TF ): 1206 1211 <br /> Final Reading(RF ): -30" -27" <br /> Test Duration: imin (min <br /> Chane in Reading(R F-RI ): 0 3 <br /> Pass/Fail Threshold or 4 4 <br /> Criteria: <br /> ?[fl Pass_ Fail` " [flPass 0 Fail '., Pass 0 Fail' <br /> Comments - (include information on repairs made prior to testing, and recommended follow-up for filler(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: Date: 11/14/2008 <br /> State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements <br />