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SWRCB,January 2006 <br /> 9. M11 Bucket Testing Repoi#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(if applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: SAN JOAQUIN COUNTY JAIL DateofTesting: 11/16/2009 <br /> Facility Address: 7000 MICHAEL CANLISS BLVD , FRENCH CAMP, CA, 95231 <br /> Facility Contact: MANAGER Phone: (8 0 0) 964-0180 <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: DANIEL ROLLINS <br /> Credentials 1: ❑CSLB Contractor [:]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:TEST WATER Equipment Resolution:LEFT ONSITE <br /> Identify Spill Bucket(By Tank 1 1 DIE FILL 2 1 DIE FILL 3 2 DIE FILL 4 <br /> Number, Stored Product, etc) <br /> Bucket Installation Type: ❑X Direct Bury X❑Direct Bury X❑Direct Bury ❑Direct Bury <br /> ❑Contained in Sump ❑ Contained in Sump ❑Contained in Sump ❑Contained in Sump <br /> Bucket Diameter: 12 1/2 12 1/2 12 1/2 <br /> Bucket Depth: 9 3/4 9 3/4 11 1/2 <br /> Wait time between applying 5 MIN 5 MIN 5 MIN <br /> vacuum/water and starting test: <br /> Test Start Time(TI ): 0930 1045 0930 <br /> Initial Reading(RI ): 9 1/4 9 1/2 11 1/4 <br /> Test End Time(TF ): 1030 1145 1030 <br /> Final Reading(RF ): 8 1/4 9 1/2 11 1/4 <br /> Test Duration: 1 HR 1 HR 1 HR <br /> Change in Reading(R F-RI ): -1 0 0 <br /> Pass/Fail Threshold or 0 0 0 <br /> Criteria: <br /> Comments- (include information 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: 12�t L � Date: 11/16/2009 <br /> I State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements <br />