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SWRCB,January 2006 <br /> w <br /> 9. S 1 Bucket Testing Reporoorm <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: COSTCO LOD I Date of Testing: 05/2 7/2 011 <br /> Facility Address: 322 E. HARNEY LANE LODI, CA, 95240 <br /> Facility Contact: MANAGER Phone: (2 0 9) 964-0180 <br /> Date Local Agency Was Notified of Testing <br /> Name of Local Agency Inspector(if present during testing): RAY VON FLUE <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: KRISTOPHER BELL <br /> Credentials 1: ❑x CSLB Contractor E ICC Service Tech. ❑SWRCB Tank Tester E Other(Specify) CONTRACTOR <br /> License Number: 7 4 316 0 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: [�] Hydrostatic Vacuum ❑ Other <br /> Test Equipment Used:TAPE MEASURE Equipment Resolution:NO VISIBLE LOSS <br /> Identify Spill Bucket(By Tank 1 3 PRE FILL 2 3 PRE VAPOR 3 4 <br /> Number, Stored Product, etc) <br /> ❑Direct Bury ❑Direct Bury ❑Direct Bury ❑Direct Bury <br /> Bucket Installation Type: ❑X Contained in Sump X❑Contained in Sump ❑Contained in Sump ❑Contained in Sump <br /> Bucket Diameter: 1311 1311 <br /> Bucket Depth: 14 If 1411 <br /> Wait time between applying 5 MIN 5 MIN <br /> vacuum/water and starting test: <br /> Test Start Time(TI ): 11:30 11:30 <br /> Initial Reading(RI ): <br /> 14" 14" <br /> Test End Time(TF ): 12:3 0 12:3 0 <br /> Final Reading(RF ): <br /> 14" 14" <br /> Test Duration: 1 HR 1 HR <br /> Change in Reading(R F-RI ): <br /> 0" 0" <br /> Pass/Fail Threshold or off Off <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: Date: 05/27/2011 <br /> 1 State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements <br />