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SWRCB, January 2006 <br />9. S1 Bucket Testing Report arm <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 <br />DateofTesting: 12/01/2008 <br />Facility Address: 1399 N. MAIN ST. @ NORTHGATE, MANTECA, CA, 95336 <br />Facility Contact: BEN <br />Phone: (2 0 9) 239-3252 <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: <br />❑ <br />CSLB Contractor <br />❑ <br />ICC Service Tech. ❑ <br />SWRCB Tank Tester <br />❑ <br />Other (Specify) <br />License Number: <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: [fl Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: tape measure <br />Equipment Resolution: no leak loss <br />Identify Spill Bucket(By Tank <br />Number, Stored Product, etc.) <br />1 4 REG FILL <br />2 5 PRE FILL <br />3 <br />4 <br />Bucket Installation Type: <br />E]Direct Bury <br />0 Contained in Sump <br />E]Direct Bury <br />Contained in Sump <br />❑ Direct Bury <br />❑Contained in Sump <br />❑ Direct Bury <br />❑Contained in Sump <br />Bucket Diameter: <br />12 <br />12 <br />Bucket Depth: <br />13 <br />12.75 <br />Wait time between applying <br />vacuum/water and starting test: <br />5 mins <br />5 mins <br />Test Start Time (Ti ): <br />910 <br />910 <br />Initial Reading (Rl ): <br />11.75 <br />11.25 <br />Test End Time (TF ): <br />1010 <br />1010 <br />Final Reading (R F ): <br />11.75 <br />11.25 <br />Test Duration: <br />1 hour <br />1 hour <br />Change in Reading (R F - RI ): <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />visual <br />visual <br />❑ Pass ❑ Fail <br />❑ Pass ❑ Fail <br />❑ Pass ❑ Fail <br />❑ Pass ❑ 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: Date: 12/01/2008 <br />1 State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements <br />