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SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intended for use by contractors performing annual testing uJLST 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#32190,MKT 2368 Date of Testing:4111/2017 <br /> Facility Address:4943 S.KINGSLEY(FRONTAGE RD)HWY 99 @ ARCH AIRPORT RD,STOCKTON,CA 95206 <br /> Facility Contact: MGR-LORENA Phone:209-939-0679 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(ifresent during testing <br /> ): <br /> 2.TESTING CONTRACTOR INFORMATION Q <br /> Company Name:TANKNOLOGY INC. <br /> Technician Conducting Test: Jesus Saldivar ,,, 71 <br /> Credentials]: r- CSLB Contractor r [CC Service Tech. r- SWRCB Tank Tester r' Other(Specify) <br /> License Number(s): <br /> 3,SPILL BUCKET TESTING INFORMATION <br /> Test Method Used By: W Hydrostatic r- Vacuum Other <br /> Test Equipment Used:LAKE TEST Equipment Resolution:0.0625 in. <br /> Identify Spill Bucket(Bv Tank Spill Box#Tank T4 RUL- Spill Box#Tank T5 MUL- Spill Sox#Tank T6 PUL- <br /> Number, Stored Product, etc.) Fill I -Direct-Grade level Fill I -Direct-Grade level Fill I-Direct-Grade level Spill Box# <br /> in containment sump in containment sump in containment sump <br /> C" Direct Bury r Direct Bury Direct Bury r Direct Bury <br /> Bucket Installation Type: r Contained in Sump r Contained in Sump ro Contained in Sump r Contained in Sump <br /> Bucket Diameter: 12.00 12.00 12.00 <br /> Bucket Depth: 13.00 13.00 14.00 <br /> Wait time between applying <br /> vacuum/water and start of test 5 min 5 min 5 min min <br /> Test Start Time(Ti): 09:00:00 09:00:00 09:00:00 <br /> Initial Reading(Rl): 13.00 in.H2O 14.00 in.H2O 14.00 in.1-120 <br /> Test End Time(TO 10:00:00 10:00:00 10:00:00 <br /> Final Reading(110: 13.00 in.H2O 14.00 in.H2O 14.00 in.1120 <br /> Test Duration(TF`Tl): I hr 1 hr 1 hr <br /> Change in Reading(RF—Rt): 0.00 in.H2O 0.00 in.H2O 0.00 in.H2O <br /> Pass/Fail Threshold or Criteria: +/-0,00 +/-0.00 +/-0.00 +1- <br /> Test Result: Pass Pass Pass <br /> Comments-(include m1brination on repairs Heade prior to testing. and recorertnended 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: da— Date: 4/11/2017 <br /> 'State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements maybe more stringent. <br /> WO:2330532 <br />