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SWRCB,January 2006 <br /> 9. S Bucket Testing ReportWrm <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: FLYING J 0500075 Date of Testing: 06/05/2008 <br /> Facility Address: 1501 N. JACK TONE RD RIPON, CA, 95366 <br /> Facility Contact: JOSE Phone: (2 0 9) 599-4141 <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: RHOME DESBIENS <br /> Credentials : ❑CSLB Contractor ❑x ICC Service Tech. ❑SWRCB Tank Tester ❑Other(Specify) <br /> License Number: <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: [K] Hydrostatic ❑ Vacuum ❑ Other <br /> Test Equipment Used: test water Equipment Resolution:site <br /> Identify Spill Bucket(By Tank 1 4 UNL FILL 2 5 PLU FILL 3 6 SUP FILL 4 1 DIE FILL <br /> Number, Stored Product, etc.) <br /> Bucket Installation Type: ❑X Direct Bury X❑Direct Bury X❑Direct Bury ❑X Direct Bury <br /> ❑Contained in Sump ❑Contained in Sump ❑Contained in Sump ❑ Contained in Sump <br /> Bucket Diameter: 11 11 11 11 <br /> Bucket Depth: 13 15 15 17 <br /> Wait time between applying <br /> vacuum/water and starting test: <br /> Test Start Time(TI ): 1248 1255 1241 <br /> Initial Reading(RI ): 11 1/21- 11 1/411 13 1/211 <br /> Test End Time(TF ): 1348 1355 1341 <br /> Final Reading(R F ): 11 1/211 11 1/411 13 1/211 <br /> Test Duration: lhr lhr lhr <br /> Change in Reading(R F-RI ): 0 0 0 <br /> Pass/Fail Threshold or 0 0 0 0 <br /> Criteria: <br /> MEMEMEMENEMEMMMEMMM I <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: 06/05/2008 <br /> 1 State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements <br />