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SWRCB,January 2006 <br /> 9. Spi11 Bucket Testing Reportyorm <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 owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> FacilityName: 7-ELEVEN #17334 MKT 2366 DateofTesting: 10/10/2011 <br /> Facility Address: 4501 N. PERSHING AVE. @ ROSEMARIE LN., STOCKTON, CA, 95207 <br /> Facility Contact: SATBIR - PERMIT: (N-747-1-6) Phone: (209) 951-6745 <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: JOEY MESA <br /> Credentials 1: [fl CSLB Contractor [fl ICC Service Tech. 0 SWRCB Tank Tester M Other(Specify) I CC SERVICE <br /> License Number: 5259458-UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: X❑ Hydrostatic Vacuum ❑ Other <br /> Test Equipment Used: TAPE MEASURE Equipment Resolution:1/8" <br /> Identify Spill Bucket(By Tank t 1 UNL FILL 2 2 PRE FILL 3 4 <br /> Number, Stored Product, etc.) <br /> X❑Direct Bury X❑ Direct Bury ❑Direct Bury ❑ 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: 16 5/8" 15" <br /> Wait time between applying 5 MIN. 5 MIN. <br /> vacuum/water and starting test: <br /> Test Start Time(TI ): 9:00 9:00 <br /> Initial Reading(RI ): 15 5/8" 14 1/4" <br /> Test End Time(TF ): 10:00 10:00 <br /> Final Reading(RF ): 15 5/8" 14 1/4" <br /> Test Duration: 60 MIN. 60 MIN. <br /> Chane in Reading(R F-RI ): 0" 0" <br /> Pass/Fail Threshold or PASS PASS <br /> Criteria: <br /> Test Result: ass ❑ Fail [::]Pass ❑ Fail ass ail <br /> Comments - (include in1brmation on repairs made prior to testing, and recommended follow-up for 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: 10/10/2011 <br /> I State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements <br />