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SWRCB,January 2006 <br /> 9. Sj,41 Bucket Testing Report orm <br /> This form is intended for use by contractors performing annual testing of UST spill containment structures. The completedform 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, CO. 123 (N-206) Date of Testing: 05/02/2008 <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: HEATH MCEVER <br /> Credentials I:❑CSLB Contractor ❑X ICC Service Tech. ❑SWRCB Tank Tester E Other(Specify) SERVICE TECH <br /> License Number: 5236756-UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: �x Hydrostatic Vacuum El Other <br /> Test Equipment Used:WATER Equipment Resolution:INCHES <br /> Identify Spill Bucket(By Tank r 1 UNL FILL z 2 SUP FILL 3 0 <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 ❑Contained in Sump <br /> Bucket Diameter: 11 11 <br /> Bucket Depth: 13 13 <br /> Wait time between applying <br /> vacuum/water and starting test: <br /> Test Start Time(TI ): 1300 1325 <br /> Initial Reading(RI ): 9 11.5 <br /> Test End Time(TF ): -1320 1425 <br /> Final Reading(RF ): 8 11.5 <br /> Test Duration: 20 MIN 1 HR <br /> Chane in Reading(R F-Ri ): 1 0 <br /> Pass/Fail Threshold or 0 0 <br /> Criteria: <br /> ME Pass ow, <br /> Comments - (include information on repairs made prior to testing, and recommended follolt-up for(nibs(t(sts) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> 1 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: 05/02/2008 <br /> I State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements <br />