Laserfiche WebLink
SWRCB, January 2006 <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 />Facility Name: 7 -ELEVEN #32262, MKT 2368 (N-3940-1 <br />Date of Testing: 05/12/2010 <br />Facility Address: 2360 W GRANTLINE I-205 OFF RAMP, TRACY, CA, 95376 <br />Facility Contact: CHANDRA <br />Phone: (2 0 9) 83 0 - 9 917 <br />Date Local Agency Was Notified of Testing: / / <br />Name of Local Agency Inspector (if present during testing): STACY RIVERA <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: TANKNOLOGY, INC. <br />Technician Conducting Test: TIMOTHY ELEBECK <br />Credentials I : <br />❑ <br />CSLB Contractor <br />E <br />ICC Service Tech. <br />E] <br />SWRCB Tank Tester <br />E Other (Specify) I CC <br />License Number: 8001435 <br />kmMul"tamLIOX I:Yx.lK E"telWI I 1_y 11 We <br />Test Method Used: <br />[X] Hydrostatic <br />❑ Vacuum <br />El Other <br />Test Equipment Used: WATER <br />MEASURMENT <br />Equipment Resolution: 1 / 8 <br />Identify Spill Bucket(By Tank <br />1 4 REG FILL <br />2 5 MID FILL <br />3 6 PRE FILL <br />4 <br />Number, Stored Product, etc) <br />Direct Bury <br />❑ Direct Bury <br />E] Direct Bury <br />❑ Direct Bury <br />Bucket Installation Type: <br />Contained in Sump <br />® Contained in Sump <br />® Contained in Sump <br />❑ Contained in Sump <br />Bucket Diameter: <br />11 <br />11 <br />11 <br />Bucket Depth: <br />15 1/2 <br />14 7/8 <br />13 7/8 <br />Wait time between applying <br />5MIN <br />5MIN <br />5MIN <br />vacuum/water and starting test: <br />Test Start Time (TI ): <br />1:15 <br />1:15 <br />1:15 <br />Initial Reading (RI ): <br />14 7/8 <br />13 7/8 <br />12 3/8 <br />Test End Time (TF ): <br />2:15 <br />2:15 <br />2:15 <br />Final Reading (R F ): <br />14 7/8 <br />13 7/8 <br />12 3/8 <br />Test Duration: <br />1HR <br />1HR <br />1HR <br />Change in Reading (R F - RI ): <br />0 <br />0 <br />0 <br />Pass/Fail Threshold or <br />P <br />P <br />P <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: 'rj-+n Date: 05/12/2010 <br />I State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements <br />