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SWRCB,January 2006 <br /> 9. Soil Bucket Testing Repor6orm <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 414117, MKT 2368 DateofTesting: 03/09/2010 <br /> Facility Address: 2725 COUNTRY CLUB BLVD STOCKTON, CA, 95204 <br /> Facility Contact: MANAGER - GIL phone: (2 0 9) 4 63-1259 <br /> Date Local Agency Was Notified of Testing: / / <br /> Name of Local Agency Inspector(if present during testing): RAY VON FLUE <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: KRISTOPHER BELL <br /> Credentials I: CSLB Contractor E ICC Service Tech. [:]SWRCB Tank Tester Other(Sped) CONTRACTOR <br /> License Number: 743160 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: Hydrostatic Vacuum Other <br /> Test Equipment Used:TAPE MEASURE Equipment Resolution:NO VISIBLE LOSS <br /> Identify Spill Bucket(By Tank 1 PRE FILL 2 2 REG FILL 3 4 <br /> Number,Stored Product, etc) <br /> X[] <br /> Bucket Installation Type: Direct Bury K❑Direct Bury Direct Bury []Direct Bury <br /> Q Contained in Sump ❑Contained in Sump ❑Contained in Sump ❑ Contained in Sump <br /> Bucket Diameter: 14" 1411 <br /> Bucket Depth: 14 1/211 14 1/211 <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 1/411 14" <br /> Test End Time(TF ): 13 .52 13 :52 <br /> Final Reading(RF ): 13 1/411 14" <br /> Test Duration: I HR 1 HR <br /> Change in Reading(R F-RI ): <br /> Oil oil <br /> Pass/Fail Threshold or 0" 0" <br /> Criteria: <br /> Test Results s Pass Fail 1fl Pass ❑ Fail 0 Pass ❑ Fail 1:1 Pass ❑ Fail <br /> Comments - (include information on repairs made prior to testing, and 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: I -- `` Date: 03/09/2010 <br /> State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements <br />