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SWRCB,January 2006 <br /> r 9. SO Bucket Testing Reporeorm <br /> This form is intended far use by contractors performing annual testing of GST spill containment structures. The completed form and <br /> printouts from tests(f applicable), should be provided to the facility owner/operator far submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: COSTCO 1031 1 Date of Testing: 01/15/2009 <br /> Facility Address: 2440 DANIELS STREET MANTECA, CA, 95336 <br /> Facility Contact: MANAGER Phone: (2 0 9) 823-0591 <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: BRIAN MCPHEELY <br /> Credentials 1: 0 CSLB Contractor [fl ICG Service Tech. ❑SWRCB Tank Tester 1:1 Other(Specify) <br /> License Number: 8010965-UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ❑ Hydrostatic " i Vacuum El Other <br /> Test Equipment Used:VACUUM DONUT Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1 1 UNL FILL z 2 ANL FILL 3 3 PRE FILL 4 <br /> Number, Stored Product, etc.) <br /> Direct Bury ❑Direct Bury Direct Bury Direct Bury <br /> Bucket Installation Type: <br /> OX Contained in Sump ® Contained in Sump FX-j Contained in Sump IQ Contained in Sump <br /> Bucket Diameter: 12 12 12 <br /> Bucket Depth: 16 15 3/4 14 1/2 <br /> Wait time between applying 30SEC 30SEC 30SEC <br /> vacuum/water and starting test: <br /> Test Start Time(TI ): 9:3 3 10:01 10:0 9 <br /> Initial Reading(RI ): 3 O INWC 3 0INWC 3 0INWC <br /> Test End Time(TF ): 9:34 10 :02 10:10 <br /> Final Reading(R F }: 2 8 INWC 2 61NWC 3 0INWC <br /> Test Duration: 60SEC 60SEC 60SEC <br /> Change in Reading(R F-RI }: 2 INWC 4 TNWC O INWC <br /> Pass/Fail Threshold or 4INWC 60SEC 4INWC 60SEC 4INWC 60SEC <br /> Criteria: <br /> Test Result Pass Fail Pass Fail lJ pass El Fail Pass Fail <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 /> Y 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: <br /> 01/15/2009 <br /> t State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements <br />