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9. S Bucket Testing Repormorm <br /> SWRCB,January 2006 <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" 0500079 Date of Testing: 06/26/2008 <br /> Facility Address: 15237 THORNTON RD LODI, CA, 95242 <br /> Facility Contact: DONNA TOMPKINS Phone: (2 0 9) 339-4066 <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: DENNIS RUE <br /> Credentials I: ❑CSLB Contractor ❑ICC Service Tech. []SWRCB Tank Tester ❑Other(Specify) <br /> License Number: <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: El Hydrostatic Vacuum 1:1 Other <br /> Test Equipment Used: TAPE MEASURE Equipment Resolution:VISUAL <br /> MUMENESEEMEMEMEMEM <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 /> QX Direct Bury X❑Direct Bury Xj Direct Bury X❑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 12 <br /> Bucket Depth: 19 20 20 12 <br /> Wait time between applying 5 5 5 5 <br /> vacuum/water and starting test: <br /> Test Start Time(TI ): 0945 0945 0945 0945 <br /> Initial Reading(RI ): 18.75 19 19 11 <br /> Test End Time(TF ): 1045 1030 1030 1045 <br /> Final Reading(RF ): 18.75 18 18 11 <br /> Test Duration: 60 MINS. 45 MINS. 45 MINS. 60 MINS. <br /> Change in Reading(R F-RI ): 0 1 1 0 <br /> Pass/Fail Threshold or p F F P <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: ,/-cl L9 _ Date: 06/26/2008 <br /> I State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements <br />