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SWRCB,January 2006 <br /> 9. Sift Bucket Testing Repor orm <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 Date of Testing: 03/31/2009 <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): GARRETT BACKUS <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: JOEY MESA <br /> Credentialsi: 0 CSLB Contractor ❑X ICC Service Tech. ❑SWRCB Tank Tester E Other(Spec) ICC SERVICE <br /> License Number: 5259458-UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ❑ Hydrostatic El Vacuum ❑ Other <br /> Test Equipment Used:TAPE MEASURE Equipment Resolution:VISUAL LOSS <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 ❑Direct Bury E]Direct Bury <br /> ❑Contained in Sump ❑ Contained in Sump ❑Contained in Sump ❑ Contained in Sump <br /> Bucket Diameter: 11" 1111 <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(TI ): 11:24 11:24 <br /> Initial Reading(RI ): <br /> 13" 13" <br /> Test End Time(TF ): 12:3 0 12 :3 0 <br /> Final Reading(RF ): <br /> 13" 13" <br /> Test Duration. 60 MIN. 60 MIN. <br /> Change in Reading(R F-RI ): <br /> 0" 0" <br /> Pass/Fail Threshold or VISUAL LOSS VISUAL LOSS <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: l1 t Date: 03/31/2009 <br /> I State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements <br />