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SWRCB,January 2006 <br /> 9. S�Prll Bucket Testing Reportwobrm <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: 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[: ❑CSLB Contractor E]ICC Service Tech. ❑SWRCB Tank Tester ❑Other(Specify) <br /> License Number. <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ❑ Hydrostatic Vacuum ❑ 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 Direct Bury K❑Direct Bury F-1Direct Bury E]Direct Bury <br /> Bucket Installation Type: <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(R] ): -30" -301- <br /> Test <br /> 30"Test End Time(TF): 1206 1211 <br /> Final Reading -30" -27" <br /> g(RF ): <br /> Test Duration: lmin lmin <br /> Change in Reading(R F-Ri ) 0 3 <br /> Pass/Fail Threshold or 4 4 <br /> Criteria, <br /> Test Result: X❑Pass ❑ Fail EKI Pass 1:1.Fail 0 Pass ❑ Fail El Pass 0 Fail <br /> Comments - (include information on repairs made prior to testing, and recommended follow-upfor failed 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 /> r State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements <br /> may be more stringent. <br />