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SWRCB,January 2006 <br /> 9. S16 Bucket Testing Reporoorm <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: TE I CHERT CONSTRUCTION Date of Testing: 02/25/2008 <br /> Facility Address: 120 FRANK WEST CIRCLE STOCKTON, CA, 95206 <br /> Facility Contact: GEORGE Phone: (916) 386-3716 <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: DANIEL ROLLINS <br /> Credentials 1: ❑CSLB Contractor ❑ICC Service Tech. ❑SWRCB Tank Tester [:]Other(Specify) <br /> License Number: <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: E] Hydrostatic Vacuum 1:1 Other <br /> Test Equipment Used:TEST WATER Equipment Resolution:REMOVED BY <br /> Identify Spill Bucket(By Tank 1 1 DIE FILL 2 2 UNL FILL 3 3 WAS FILL 4 <br /> Number,Stored Product, etc) <br /> Direct Bury ❑Direct Bury ❑Direct Bury F-1DirectBury <br /> Bucket Installation Type: 0 Contained in SumpXO Contained in Sump Q Contained in Sump ❑Contained in Sump <br /> Bucket Diameter: 11 11 11 <br /> Bucket Depth: 13 13 13 <br /> Wait time between applying 5 MIN 5 MIN 5 MIN <br /> vacuum/water and starting test: <br /> Test Start Time(TI ): 0920 1055 1055 <br /> Initial Reading(RI ): 13 13 13 <br /> Test End Time(TF ): 1020 1155 1155 <br /> Final Reading(RF ): 13 13 13 <br /> Test Duration: 1 HR 1 HR 1 HR <br /> Change in Reading(R F-RI ): 0 0 0 <br /> Pass/Fail Threshold or 0 0 0 <br /> Criteria: <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: J ,2U J Date: 02/25/2008 <br /> 1 State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements <br />