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SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This farm 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#32190,MKT 2368 1 Date of Testing:4/9/2018 <br /> Facility Address:4943 S.KEQGSLEY(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:4/6/2018 <br /> Name of Local Agency Inspector(ifpresent during testing):UNKOWN <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name:TANKNOLOGY INC. <br /> Technician Conducting Test:Jesus Saldivar <br /> Credentials): r CSLB Contractor r ICC Service Tech. r SWRCB Tank Tester r Other(Specify) <br /> License Number(s): <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used By: V Hydrostatic r Vacuum r Other <br /> Test Equipment Used:LAKE TEST Equipment Resolution:0.0625 in. <br /> Identify Spill Bucket(By Tank Spill Box#Tank T4 RUL- Spill Box#Tank T5 MUL- Spill Box#Tank T6 PUL- <br /> Number,Stored Product, etc) Fill I -Direct-Grade level FID 1 -Direct-Grade level Fill I-Direct-Grade level Spill Box# <br /> in containment sump in containment sump in containment sump <br /> r Direct Bury r Direct Bury r" Direct Bury C Direct Bury <br /> Bucket Installation Type: G Contained in Sump G Contained in Sump r Contained in Sump r" Contained in Sump <br /> Bucket Diameter: 12.00 12.00 12.00 <br /> Bucket Depth: 13.00 14.00 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(RI): 13.00 in.H2O 14.00 in.H2O 14.00 in.H2O <br /> Test End Time(TF): 10:00:00 10:00:00 10:00:00 <br /> Final Reading(RF): 13.00 in.H2O 14.00 in.1120 14.00 in.H2O <br /> Test Duration(TF—TI): I hr 1 hr 1 hr <br /> Change in Reading(Ry—RI): 0.00 in.H2O 0.00 in.H2O 0.00 in.H2O <br /> Pass/Fail Threshold or Criteria: +/-0.00 +/-0.00 +/-0.00 +/- <br /> Test Result: Pass Pass Pass <br /> Comments-(include information on repairs made prior to testing, and recommended fallow-up for failed tests) <br /> CERTIFICATION OF TECIINICLAN 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: �-1?4L Date: 4/9/2018 <br /> [State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements may be more stringent. <br /> WO:2335400 <br />