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SWRCB,January 2006 <br /> 9. Sill Bucket Testing Report`F'orm <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(ifapplicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> FacilityName: CIRCLE K 2701205 Date of Testing: 10/22/2009 <br /> Facility Address: 16470 CAMBRIDGE @ LOUISE, LATHROP, CA, 95330 <br /> Facility Contact: MANAGER-ROBERT Phone: (209) 858-4116 <br /> Date Local Agency Was Notified of Testing <br /> Name of Local Agency Inspector(if present during testing): MICHELLE <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: KRISTOPHER BELL <br /> Credentials]:❑CSLB Contractor ❑X ICC Service Tech. ❑SWRCB Tank Tester 0 Other(Spec) <br /> License Number: 5297793-ut <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ❑X Hydrostatic Vacuum ❑ Other <br /> Test Equipment Used: TAPE MEASURE Equipment Resolution:NO VISIBLE LOSS <br /> Identify Spill Bucket(By Tank r I UNL FILL 2 2 SUP FILL 3 4 <br /> Number, Stored Product, etc) <br /> Bucket Installation Type: X❑Direct Bury X❑Direct Bury E]Direct Bury ❑Direct Bury <br /> ❑Contained in Sump ❑Contained in Sump El Contained in Sump El Contained in Sump <br /> Bucket Diameter: 1411 1411 <br /> Bucket Depth: 13" 1211 <br /> Wait time between applying 1 MIN 1 MIN <br /> vacuum/water and starting test: <br /> Test Start Time(T] ): 8:48 8:48 <br /> Initial Reading(RI ): <br /> 13" 12" <br /> Test End Time(TF): 9:48 9:48 <br /> Final Reading(R F ): 13" 12" <br /> Test Duration: 1 HR 1 HR <br /> Change in Reading(R F-RI ): <br /> 0" 0" <br /> Pass/Fail Threshold or 0" 0" <br /> Criteria: <br /> Test Result: [L]Pass E Fail x❑Pass E Fail ❑Pass E1 Fail E Pass ❑ Fail <br /> Comments- (include information on repairs made prior to testing, and recommended follow-up forfailed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> 1 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: 10/22/2009 <br /> 1 State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements <br /> may be more stringent. <br />