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SWRCB, January 2006 <br />9. S^ Bucket Testing Repor0orm <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 />FacilityName: 7 -ELEVEN #32262, MKT 2368 (N-3940-1 <br />DateofTesting: 04/08/2011 <br />Facility Address: 2360 W GRANTLINE I-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): Inspector Onsite <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: TANKNOLOGY , INC. <br />Technician Conducting Test: JON ADAMS <br />Credentials): <br />[K] Hydrostatic <br />CSLB Contractor <br />E <br />ICC Service Tech. <br />❑ <br />SWRCB Tank Tester E Other (Specify) A <br />License Number: 743160 <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: ��.4--5 Date: <br />04/08/2011 <br />I State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: <br />[K] Hydrostatic <br />❑ Vacuum <br />❑ Other <br />Test Equipment Used: water <br />and tape measure <br />Equipment Resolution: 1/16" <br />SEENEEMEMENOM <br />Identify Spill Bucket(By Tank <br />1 5 MID FILL <br />2 6 PRE FILL <br />3 4 REG FILL 4 <br />Number, Stored Product, etc.) <br />❑ Direct Bury <br />E] Direct Bury <br />❑ Direct Bury E] Direct Bury <br />Bucket Installation Type: <br />® Contained in Sumpx❑ <br />Contained in Sump <br />® Contained in Sump ❑ Contained in Sump <br />Bucket Diameter: <br />12 <br />12 <br />12 <br />Bucket Depth: <br />13 1/2 <br />12 1/2 <br />14 1/4 <br />Wait time between applying <br />1 min <br />1 min <br />1 min <br />vacuum/water and starting test: <br />Test Start Time (TI ): <br />1030 <br />1030 <br />1030 <br />Initial Reading (RI ): <br />13 <br />12 <br />14 <br />Test End Time (TF ): <br />113 0 <br />1130 <br />1130 <br />Final Reading (RF ): <br />13 <br />12 <br />14 <br />Test Duration: <br />1 hr <br />1 hr <br />1 hr <br />Change in Reading (R F - RI ): <br />0 <br />0 <br />0 <br />Pass/Fail Threshold or <br />0 <br />0 <br />0 <br />Criteria: <br />mmmm <br />Nam <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: ��.4--5 Date: <br />04/08/2011 <br />I State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements <br />