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SWRCB, January 2006 <br />9. Spill Bucket Testing Report Form <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 ownerloperatorfor submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: 7 -ELEVEN #32262, MKT 2368 (N-3940-1 DateofTesting: 05/12/2010 <br />Facility Address: 2360 W GRANTLINE 1-205 OFF RAMP, TRACY, CA, 95376 <br />Facility Contact: CHANDRA —Tphone: <br />(209) 830-9917 <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 />0 <br />CSLB Contractor E ICC Service Tech. [:] SWRCB Tank Tester E] Other (Specify) ICC <br />License Number: 8001435 <br />1 1 <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: <br />[K] Hydrostatic <br />❑ Vacuum <br />El Other <br />Test Equipment Used: WATER MEASURMENT <br />Equipment Resolution: l/8 <br />Identify Spill Bucket(By Tank <br />Number, Stared Product, etc.) <br />i 4 REG FILL <br />2 5 MID FILL <br />3 6 PRE FILL <br />4 <br />Bucket Installation Type: <br />Direct Bury 1:1 Direct Bury <br />EZ Contained in Sump Contained in Sump <br />E] Direct Bury <br />Contained in Sump <br />®Direct Bury <br />Ej 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 />vacuum/water and starting test: <br />5MIN <br />SMIN <br />SMIN <br />Test Start Time (TI <br />1: 15 <br />1:15 <br />1: 15 <br />-Initial Reading (R 1 <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 - R1 <br />0 <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />P <br />P <br />P <br />1"i <br />0 i <br />E— <br />Mr -M <br />All, <br />v, <br />Comments - (include information on repairs made prior to testing, and recommended follow-up far 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: 05/12/2010 <br />State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements <br />