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9. SpI Bucket Testing Report corm SWRCB, January 2006 <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 #19976, MKT 2368 <br />1 DateofTesting: 10/03/2011 <br />Facility Address: 1399 N. MAIN ST. @ NORTHGATE, MANTECA, CA, 95336 <br />Facility Contact: BEN- (PERMIT: N-745-1-4) <br />Phone: (209) 239-3252 <br />Date Local Agency Was Notified of Testing: / / <br />Name of Local Agency Inspector (if present during testing): THUY <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: TANKNOLOGY, INC. <br />Technician Conducting Test: TIMOTHY COULTER <br />Credentials is <br />E <br />CSLB Contractor E <br />ICC Service Tech. ❑ SWRCB Tank Tester E <br />Other (Spec) UT -A <br />License Number: 5295244-734160 <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: X❑ Hydrostatic D Vacuum ❑ Other <br />Test Equipment Used: TAPE MEASURE <br />Equipment Resolution: V I S UAL <br />Identify Spill Bucket(By Tank <br />Number, Stored Product, etc.) <br />t 4 REG FILL <br />Z 5 PRE FILL <br />3 <br />4 <br />Bucket Installation Type: <br />❑ Direct Bury <br />X❑ Contained in Sump[K] <br />E]Direct Bury <br />Contained in Sump <br />E]Direct Bury <br />❑ Contained in Sump <br />❑ Direct Bury <br />❑ Contained in Sump <br />Bucket Diameter: <br />10 <br />10 <br />Bucket Depth: <br />10 <br />10 <br />Wait time between applying <br />vacuum/water and starting test: <br />10 MINS <br />10 MINS <br />Test Start Time (TI ): <br />1130 <br />1130 <br />Initial Reading (RI ): <br />9 <br />9 <br />Test End Time (TF ): <br />1230 <br />1230 <br />Final Reading (RF ): <br />9 <br />9 <br />Test Duration: <br />1 HR <br />1 HR <br />Chane in Reading (R F - RI ): <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />0 <br />0 <br />Test Result: <br />El Pass ❑ Fail <br />E Pass ❑ Fail <br />ElPass D Fail <br />❑ Pass D 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 />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: L_�G Date: 10/03/2011 <br />I State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements <br />