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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 owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: 7-ELEVEN #14117, MKT 2368 Dake of Testing: 03/09/2010 <br /> Facility Address: 2725 COUNTRY CLUB BLVD STOCKTON, CA, 95204 <br /> Facility Contact: MANAGER - GIL Phone: (209) 463-1259 <br /> Date Local Agency Was Notified of Testing : / / <br /> Name of Local Agency Inspector(if present during testing): RAY VON FLUE <br /> Z. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: KRISTOPHER BELL <br /> Credentials I: El CSLB Contractor [�]ICC Service Tech. ❑SWRCB Tank Tester ❑Other(Specify) CONTRACTOR <br /> License Number: 743160 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: [K] Hydrostatic ❑ Vacuum ❑ Other <br /> Test Equipment Used:TAPE MEASURE Equipment Resolution:NO VISIBLE LOSS <br /> Identify Spill Bucket(By Tank t 1 PRE FILL 2 2 REG FILL 3 a <br /> Number, Stored Product, etc) <br /> Bucket Installation Type: ®Direct Bury X❑Direct Bury ElDirect Bury ❑Direct Bury <br /> ❑Contained in Sump [] Contained in Sump ❑Contained in Sump ❑Contained in Sump <br /> Bucket Diameter: 141, 14 <br /> Bucket Depth: 14 1/21, 14 1/21, <br /> Wait time between applying 5 MIN 5 MIN <br /> vacuum/water and starting test: <br /> Test Start Time(TI ): 12:52 12:52 <br /> Initial Reading(RI ): 13 1/41, 14" <br /> Test End Time(TF}: 13:52 13:52 <br /> Final Reading(RF ): 13 1/411 14" <br /> Test Duration: 1 HR 1 HR <br /> Change in Reading(R F-RI <br /> Pass/Fail Threshold or 0„ 011 <br /> Criteria: <br /> Test Result: Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑Pass Fail <br /> ComIncnts- (include information on repairs made prior to testing, and recommended follosi'-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: 03/09/2010 <br /> State laws and regulations do not currently require testing to be perfomied by a qualified contractor.However,local requirements <br /> may be more stringent. <br />