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SWRCB,January 2006 <br /> 9. Skil Bucket Testing Repor%. orm <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(ifopplicable),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 2368 (N-747) Dateof Testing: 10/12/2010 <br /> Facility Address: 4501 N. PERSHING AVE. @ ROSEMARIE IN. , STOCKTON, CA, 95207 <br /> Facility Contact: MGR - SATBIR Phone: (209) 951-6745 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): GARRETT <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: JON ADAMS <br /> Credentials 1: ❑X CSLB Contractor ❑X ICC Service Tech. ❑SWRCB Tank Tester 1fl Other(Specify)A <br /> License Number: 743160 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: 0 Hydrostatic ❑X Vacuum ❑ Other <br /> Test Equipment Used:VACUUM DONUT AND MAGNEHELICH GAUGE Equipment Resolution:1' <br /> Identify Spill Bucket(By Tank i 1 UNL FILL Z 2 PRE FILL 3 0 <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: 12 12 <br /> Bucket Depth: 14.5 14.25 <br /> Wait time between applying 1MIN 1MIN <br /> vacuum/water and starting test: <br /> Test Start Time(Ti ): 0900 0903 <br /> Initial Reading(Ri ): -30 -30 <br /> Test End Time(TF ): 0902 0905 <br /> Final Reading(RF ): -26 -30 <br /> Test Duration: 1MIN 1MTN <br /> Change in Reading R F-Ri ): -4 0 <br /> Pass/Fail Threshold or -4 -4 <br /> Criteria: <br /> Test Result: X❑Pass ElFail X Pass Fail Passe Fail D Pass Fail <br /> Comments - (include information on repairs made prior to testing, and recommended follow-up for jailed 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:�� . (V i�� Date: 10/12/2010 <br /> State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements <br />