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SWRCB,January 2006 <br /> 9. Sj,;1 Bucket Testing Report.;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(if applicable),should be provided to the facility owner/operatorfor submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: CIRCLE K 2701205 Date of Testing: 10/14/2010 <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): THUY TRAN <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: KELVIN CRUZ <br /> Credentialsi: ❑K CSLB Contractor E ICC Service Tech. ❑SWRCB Tank Tester ❑K 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:1/16" <br /> Identify Spill Bucket(By Tank I UNL FILL z 2 SUP FILL 3 4 <br /> Number,Stored Product, etc) <br /> ❑X Direct Bury X❑Direct Bury ❑Direct Bury ❑Direct Bury <br /> Bucket Installation Type: <br /> ❑Contained in Sump ❑Contained in Sump ❑Contained in Sump ❑Contained in Sump <br /> Bucket Diameter: 11 11 <br /> Bucket Depth: 13 13 <br /> Wait time between applying 5MIN 5MIN <br /> vacuum/water and starting test: <br /> Test Start Time(TI ): 0927 0927 <br /> Initial Reading(Rt ): 12 5/8 11 /58 <br /> Test End Time(TF ): 1027 1027 <br /> Final Reading(RF ): 12 5/8 11 5/8 <br /> Test Duration: 1HR 1HR <br /> Change in Reading(R F-RI ): 0 0 <br /> Pass/Fail Threshold or 0 0 <br /> Criteria: <br /> Test <br /> Comments - (include information on repairs made prior to testing,and recommended follow-upforfailed 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: 10/14/2010 <br /> I State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements <br />