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SWRCB,January 2006 <br /> 9. Sll Bucket Testing Reporoorm <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 #32190 (N-3810) , MKT 2366 Dateof Testing: 12/15/2008 <br /> Facility Address: 4943 S. KINGSLEY (FRONTAGE RD) HWY 99 @ ARCH AIRPORT RD, STOCKTON, CA, <br /> Facility Contact: MGR - LORENA Phone: (209) 939-0679 <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 1: [:]CSLB Contractor ❑ICC Service Tech. ❑SWRCB Tank Tester ❑Other(Specify) <br /> License Number: <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: [K] Hydrostatic Vacuum ❑ Other <br /> Test Equipment Used: tape measure Equipment Resolution:no leak loss <br /> Identify Spill Bucket(By Tank 3 PRE FILL 2 4 REG FILL 3 5 MID FILL 4 <br /> Number,Stored Product, etc) <br /> ❑Direct Bury ❑Direct Bury ❑Direct Bury ❑Direct Bury <br /> Bucket Installation Type: x❑ Contained in Sum X Contained in Sum x Contained in p ❑ p ❑ Sump ❑ Contained in Sump <br /> Bucket Diameter: 11 11 11.50 <br /> Bucket Depth: 15 15 15 <br /> Wait time between applying 5 mins 5 mins 5 mins <br /> vacuum/water and starting test: <br /> Test Start Time(TI ): 1029 1029 1029 <br /> Initial Reading(Rt ): 13 .75 13.50 13 .75 <br /> Test End Time(TF): 1135 1135 1135 <br /> Final Reading(RF ): 13 .75 13.50 13.75 <br /> Test Duration: 1 hour 1 hour 1 hour <br /> Change in Reading(R F-Ri ): 0 0 0 <br /> Pass/Fail Threshold or visual visual visual <br /> Criteria: <br /> Test Result: IT]Pass ❑ Fail x❑Pass 0 Fail x❑Pass ❑ Fail 0 Pass ❑ Fail <br /> Comments- (include information on repan:r made prior to testing, and recommended follow-up forfailed 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: � 0!Qq' . Date: 12/15/2008 <br /> t State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements <br />