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SWRCB,January 2006 <br /> 9. S11 Bucket Testing Repor Form <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 #19976, MKT 2368 DateofTesting: 11/06/2009 <br /> Facility Address: 1399 N. MAIN ST. @ NORTHGATE, MANTECA, CA, 95336 <br /> Facility Contact: BEN Phone: (2 0 9) 239-3252 <br /> Date Local Agency Was Notified of Testing <br /> Name of Local Agency Inspector(if present during testing): MOONIE <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: KRISTOPHER BELL <br /> Credentials 1: ❑CSLB Contractor ❑X ICC Service Tech. ❑SWRCB Tank Tester 0 Other(Specify) <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 <br /> 4 REG FILL Z 5 PRE FILL 3 4 REG FILL 4 <br /> Number,Stored Product, etc) <br /> El Direct Bury E]Direct Bury ❑Direct Bury ❑Direct Bury <br /> Bucket Installation Type: ❑Contained in Sump X❑Contained in SumpXO Contained in Sump ❑Contained in Sump <br /> Bucket Diameter: 14 1411 1411 <br /> Bucket Depth: 13 1/211 121/2" 13 1/211 <br /> Wait time between applying 1 MIN 1 MIN 1 MIN <br /> vacuum/water and starting test: <br /> Test Start Time(Tl ): 8:58 8 :5 8 10:27 <br /> Initial Reading(Rl ): 13" 1211 13 1/411 <br /> Test End Time(TF ): 9:58 9:58 11:27 <br /> Final Reading(R F ): 12 1/2" 12" 13 1/4" <br /> Test Duration: 1 HR 1 HR 1 HR <br /> Change in Reading(R F-RI ): <br /> 1/2" 0" 0" <br /> Pass/Fail Threshold or 0" 0" oil <br /> Criteria: <br /> Test Result: ❑Pass ❑ Fail Pass ❑ .Fail ❑Pass ❑ Fail ❑ Pass ❑ Fail <br /> Comments - (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> REPLACED 87 DUST CAP AND RETESTED 87 SPILL BUCKET. <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: 11/06/2009 <br /> 1 State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements <br />