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! SWRCB,January 2006 <br /> 9. ill Bucket Testing Rep4w Form <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: FLYING J 0500075 Date of Testing: 05/31/2007 <br /> Facility Address: 1501 N. JACK TONE RD RIPON, CA, 95366 <br /> Facility Contact: JOSE Phone: (2 0 9) 599-4141 <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: DOUGLAS HARTY <br /> Credentials I: E CSLB Contractor []ICC Service Tech. [:]SWRCB Tank Tester [fl Other(Specify) 743160 <br /> License Number: <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: Hydrostatic El Vacuum ❑ Other <br /> Test Equipment Used: Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1 1 DIE FILL 2 2 DIE FILL 3 3 DIE FILL 4 4 UNL FILL <br /> Number, Stored Product, etc) <br /> E]Direct Bury ❑Direct Bury E]Direct Bury ❑Direct Bury <br /> Bucket Installation Type: <br /> ❑Contained in Sump ❑Contained in Sump ❑Contained in Sump ❑ Contained in Sump <br /> Bucket Diameter: 12 12 12 11 <br /> Bucket Depth: 17 17 17 10 <br /> Wait time between applying 1 MIN 1 MIN 1 MIN 1 MIN <br /> vacuum/water and starting test: <br /> Test Start Time(TI ): 10:00 10:00 10:00 10:2 0 <br /> Initial Reading(RI ): 12 12 12 10 <br /> Test End Time(TF ): 11:00 11:00 11:00 11:20 <br /> Final Reading(RF ): 12 12 12 10 <br /> Test Duration: 1 HR 1 HR 1 HR 1 HR <br /> Change in Reading(R F-RI ): 0 0 0 0 <br /> Pass/Fail Threshold or VISIBLE LOSS VISIBLE LOSS VISIBLE LOSS VISIBLE 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: FN Date: 05/31/2007 <br /> I State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements <br />