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SWRCB,January 2006 <br /> 9. S101 Bucket Testing Reporworm <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(f 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: 03/17/2010 <br /> Facility Address: 4627 DA VINCI DR @ MARCH LN, STOCKTON, CA, 95207 <br /> Facility Contact: MGR - SATBIR (PTO# N-748) Phone: (209) 952-3543 <br /> Date Local Agency Was Notified of Testing: 03/11/2010 <br /> Name of Local Agency Inspector(if present during testing): garrett <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: STEVEN WILLEMS <br /> Credentials]: ❑x CSLB Contractor E ICC Service Tech. ❑SWRCB Tank Tester ❑x Other(Specify) i cc <br /> License Number: 8016974 ut <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: x❑ Hydrostatic 1:1 Vacuum ❑ Other <br /> Test Equipment Used: tape measure Equipment Resolution:1/8 inch <br /> Identify Spill Bucket(By Tank 1 1 REG FILL 2 2 PRE FILL 3 4 <br /> Number, Stored Product, etc) <br /> Bucket Installation Type: X❑Direct Bury X❑Direct Bury F-1Direct Bury ❑Direct Bury <br /> ❑Contained in Sump ❑ Contained in Sump ❑Contained in Sump ❑Contained in Sump <br /> Bucket Diameter: 12 12 <br /> Bucket Depth: 14.25 14.25 <br /> Wait time between applying 5 mins 5 mins <br /> vacuum/water and starting test: <br /> Test Start Time(TI ): 0924 0924 <br /> Initial Reading(RI ): 14 13.5 <br /> Test End Time(TF ): 1024 1024 <br /> Final Reading(RF ): 14 13.5 <br /> Test Duration: 1 hour 1 hour <br /> Change in Reading(R F-RI ): 0 0 <br /> Pass/Fail Threshold or visual visual <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: (! Date: 03/17/2010 <br /> J <br /> 1 State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements <br />