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SWRCB,January 2006 <br /> 9. S Bucket Testing eor or <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 #20632, MKT 2368 DateofTesting: 02/17/2011 <br /> Facility Address: 4627 DA VINCI DR @ MARCH LN, STOCKTON, CA, 95207 <br /> Facility Contact: MGR - SATBIR (PTO# N-748) Phone: (2 09) 952-3 543 <br /> Date Local Agency Was Notified of Testing: / / <br /> Name of Local Agency Inspector(if present during testing): GARETT <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: KRISTOPHER BELL <br /> Credentials 1: a CSLB Contractor E ICC Service Tech. ❑SWRCB Tank Tester E Other(Specify) CONTRACTOR <br /> License Number: 743160 <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 1 1 REG FILL 2 2 PRE 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: 1311 1311 <br /> Bucket Depth: 14 1/211 14 1/211 <br /> Wait time between applying 5 MIN 5 MIN <br /> vacuum/water and starting test: <br /> Test Start Time(Tl ): 8:45 8:45 <br /> Initial Reading(Rl ): 13 3/411 14" <br /> Test End Time(TF ): 9:45 9:45 <br /> Final Reading(RF ): 13 3/411 14" <br /> Test Duration: 1 HR 1 HR <br /> Change in Reading(R F-Ri ): <br /> 0" 0" <br /> Pass/Fail Threshold or oil oil <br /> Criteria: <br /> Comments- (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> CERTIFICATION OF TECIINICIAN 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: 02/17/2011 <br /> 1 State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements <br />