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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 agAU 19 2016 <br /> 1.FACILITY INFORMATION ":p r�` aIE <br /> Facility Name:7-ELEVEN#132190,MKT 2368 Date of Testing:4/13/201'6~x+ .4 FW0414r6, <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(ifpresent during testing): <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name:TANKNOLOGY INC. <br /> Technician Conducting Test:Nicolas Poblano <br /> Credentials): r CSLB Contractor r [CC Service Tech. r SWRCB Tank Tester F Other(Specify) <br /> License Number(s): <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used By: r hydrostatic (— Vacuum r Other <br /> Test Fquipmcnt llscd: kquipment Resolution: <br /> Identify Spill Bucket(By Tank Spill Box#'Tank T4 RUL- Spill Box#Tank T5 MUL- Spill Box#Tank T6 PIJL- <br /> tVumber, Stored Product, etc.) Fill l -Direct-Grade level Fill I -Direct-Grade level Fill 1 -Direct-Grade level Spill Box# <br /> in containment sump in containment sump in containment sump <br /> C Direct Bury (' Direct Bury C Direct Bury r Direct Bury <br /> Bucket Installation Type: tr Contained in Sump f+ Contained in Sump lr Contained in Sump f' Contained in Sump <br /> Bucket Diameter: 10.00 10.00 10.00 <br /> Bucket Depth: 16.00 16.00 16.00 <br /> Wait time between applying <br /> vacuum/water and start of test 5 min 5 min 5 min min <br /> Test Start Time(Tl): 09:30:00 09:30:00 09:30:00 <br /> Initial Reading(Rl): 15.00 in. 15.1250 in. 15.25 <br /> Test End Time(TF): 10:30:00 10:30:00 10:30:00 <br /> Final Reading(RF): 15.00 in. 15.1250 in. 15.25 <br /> Test Duration(TF—Tt): 1 hr I hr 1 hr <br /> Change in Reading(RF—Rl): 0.00 in. 0.00 in. 0.00 <br /> Pass/Fail Threshold or Criteria: +/-0.00 +/-0.00 +/-0.00 +1- <br /> Test Result: Pass Pass Pass <br /> Comments-(include inforniafion on repairs made prior to testing, and reconzutencled falioii�-up for-failed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the information container)in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: Date: 4/13/2016 <br /> t5tate laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements may be more stringent. <br /> W0.2326252 <br />