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SWRCB, January 2006 <br />t BucketTesting' i i <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 />1ENRM= <br />Facility Name: 7 -ELEVEN #32262,. MKT 2368 (N-3940) <br />DateofTesting: 05/12/2009 <br />Facility Address: 2360 W GRANTLINE 1-205 OFF RAMP, TRACY, CA, 95376 <br />Facility Contact: CHANDRA <br />Phone: (2 0 9) 830-9917 <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: STEVEN WILLEMS <br />Credentials t : 0 CSLB Contractor Q ICC Service Tech. ❑ SWRCB Tank Tester 11 Other (Specify) <br />License Number: <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: <br />X❑ Hydrostatic El Vacuum ❑ Other <br />Test Equipment Used: tape measure <br />Equipment Resolution: no leak loss <br />EMENESEEM <br />Identify Spill Bucket(By Tank 1 <br />Number, Stored Product, etc) <br />4 REG FILL <br />2 5 MID FILL <br />3 6 PRE FILL <br />4 <br />Bucket Installation Type: <br />Direct Bury <br />® Contained in Sump <br />Direct Bury <br />® Contained in Sump <br />F-1Direct Bury <br />® Contained in Sump <br />F-1Direct Bury <br />❑ Contained in Sump <br />Bucket Diameter: <br />12 <br />12 <br />12 <br />Bucket Depth: <br />15.75 <br />15.25 <br />14 <br />Wait time between applying <br />vacuum/water and starting test: <br />5 mins <br />5 mins <br />5 mins <br />Test Start Time (TI ): <br />1213 <br />1213 <br />1213 <br />Initial Reading (RI ): <br />14.75 <br />14 <br />12.5 <br />Test End Time (TF ): <br />1313 <br />1313 <br />1313 <br />Final Reading (RF ): <br />14.75 <br />14 <br />12.5 <br />Test Duration: <br />1 hour <br />1 hour <br />1 hour <br />Change in Reading (R F - RI ): <br />0 <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />visual <br />visual <br />visual <br />CO11 MentS - (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: Q Date <br />05/12/2009 <br />I State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements <br />