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� J <br />SWRCB, January 2006 <br />Spill Bucket Testing Report Form <br />This form is intendedfor use by contractors performing annual testing of UST spill containment structures. The co le ted or `�/ <br />printouts from tests (ifapplicable), should be provided to the facility owner/operator for submittal to the local regi eNea9��c %ill <br />FACILITY INFORMATION <br />JUL 2 5 2016 <br />Facility Name: 7 -ELEVEN #17647, MKT 2368 (N-744) Date of Testing: 7/19/201 <br />Facility Address: 1048 W. YOSEMITE AVE @ EL PORTEL, MANTECA, CA 95336-_ `l;. �l♦ .4 ate- .. <br />Facility Contact: DEALER-ANTWAN Phone: 209-239-2329 <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (if present during testing): unknown <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: TANKNOLOGY INC. <br />Technician Conducting Test: Jarrod Cooke <br />Credentials]: ❑ CSLB Contractor r ICC Service Tech. i— S\ARCB lank Tester r— Other (Speufj) <br />License Number(s): 8155550 <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used By: r I ladrostatic W Vacuum r Other <br />Fest Equipment Used: LAKE TEST Equipment Resolution: 0.0625 in. <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc) <br />Spill Box # Tank'F-1 RUL - <br />Fill I - Direct - Grade level <br />Spill Box # Tank T-2 PUL - <br />Fill 1 - Direct - Grade levet <br />Spill Box # <br />Spill Box # <br />Bucket Installation Type: <br />4 Direct Bury <br />N Contained in Sump <br />A Direct Bury <br />A Contained in Sump <br />r Direct Bury <br />G Contained in Sump <br />4 Direct Bury <br />0 Contained in Sump <br />Bucket Diameter: <br />14.00 <br />14.00 <br />Bucket Depth: <br />10.00 <br />10.00 <br />Wait time between applying <br />vacuum/water and start of test <br />0 min <br />5 min <br />min <br />mm <br />Test Start Time (Tir <br />09:12:00 <br />09:25:00 <br />Initial Reading (RI): <br />30.00 in. H2O <br />10.00 in. <br />Test End Time(TF): <br />09:13:00 <br />10:25:00 <br />Final Reading (RF): <br />28.00 in. H2O <br />10.00 in. <br />Test Duration(TF—TI): <br />I min <br />1 hr <br />Change in Reading (RF—Rt) : <br />-2.00 in. H2O <br />0.00 in. <br />Pass/Fail Threshold or Criteria: <br />+/-4,00 <br />+/-0.00 <br />+/- <br />+/- <br />Test Result: <br />Pass <br />Pass <br />Comments - (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />CERTIFICATION OF TECBN1CI4,N RESPONSIBLE FOR CONDUCTING THIS T MING <br />hereby certify that all the information contained in this report is true, accurate, and in full compliance with legal requirements. <br />Technician's Signature: Date: 7/192016 <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: 232]3]3 <br />