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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 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 #19976, MKT 2368 <br />Date of Testing: 9/19/2017 <br />Facility Address: 1399 N. MAIN ST. @ NORTHGATE, MANTECA. CA 95336 <br />Facility Contact: BEN Phone: 209-239-3252 <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: Jesus Saldivar <br />Credentials): r CSLB Contractor 7' ICC Service Tech. SWRCB Tank Tester r Other (Specify) <br />License Number(s): <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used By: P-0 Hydrostatic r vacuum f Other <br />Test Equipment Used: LAKE TEST I Equipment Resolution: 0.0625 in. <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc) <br />Spill Box # Tank <br />T41 NLEADED RUL - Fill 1 <br />- Direct - Grade level in <br />containment sump <br />Spill Box # Tank <br />T5:PRENUW PUL - Fill 1- <br />Direct - Grade level in <br />containment sump <br />Spill Box # <br />Spill Box # <br />Bucket Installation Type: <br />Direct Bury <br />0 Contained in Sump <br />6` Direct Bury <br />f Contained in Sump <br />f Direct Bury <br />f Contained in Sump <br />Direct Bury <br />Contained in Sump <br />Bucket Diameter: <br />12.00 <br />12.00 <br />Bucket Depth: <br />13.00 <br />13.00 <br />Wait time between applying <br />and start of test <br />5 min <br />5 min <br />min <br />millvacuum/water <br />Test Start Time (TI): <br />08:00:00 <br />08:00:00 <br />Initial Reading (RI): <br />13.00 in. H2O <br />13.00 in. H2O <br />Test End Time(TO <br />09:00:00 <br />09:00:00 <br />Final Reading (RF): <br />13.00 in. H2O <br />13.00 in. H2O <br />Test Duration(TF—TI): <br />1 hr <br />I hr <br />Change in Reading (RF—RI): <br />0.00 in. H2O <br />0.00 in. H2O <br />Pass/Fail Threshold or Criteria: <br />+/-0.00 <br />+/-0.00 <br />Test Result: <br />Pass <br />Pass <br />Comments - (include information on repairs made prior to testing, and recommended follow-up for Jailed tests) <br />CERTIFICATION OF TECBMCIAN RESPONSIBLE FOR CONDUCTING TMS 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: AlJ&—. <br />Date: 9/19/2017 <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: 2332344 <br />