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SWRCB,January 2006 <br /> 9. Split Bucket Testing Report - r <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 DateofTesting: 06/26/2008 <br /> Facility Address: 15237 THORNTON RD LOD I, 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 1:1 ICC Service Tech. 1:1 SWRCB Tank Tester ❑Other(Specify) <br /> License Number: <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: M Hydrostatic El Vacuum D Other <br /> Test Equipment Used:TAPE MEASURE Equipment Resolution:VISUAL <br /> Identify Spill Bucket(By Tank 1 5 PRE FILL 2 3 4 <br /> Number, Stored Product, etc) <br /> ❑X Direct Bury ❑Direct Bury E]Direct Bury E]Direct Bury <br /> Bucket Installation Type: <br /> ❑ Contained in Sump ❑ Contained in Sump ❑Contained in Sump ❑ Contained in Sump <br /> Bucket Diameter: 12 <br /> Bucket Depth: 12 <br /> Wait time between applying 5 <br /> vacuum/water and starting test: <br /> Test Start Time(TI ): 0945 <br /> Initial Reading(RI ): 11 <br /> Test End Time(TF ): 1045 <br /> Final Reading(RF ): 11 <br /> Test Duration: 60 MINS. <br /> Change in Reading(R F-RI ): 0 <br /> Pass/Fail Threshold or 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: .'g,/'-c' A 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 />