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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.Rhe ECEIVED <br /> printouts from tests(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> NOV 0 8 2016 <br /> 1.FACILITY INFORMATION <br /> Facility Name:7-ELEVEN#19976,MKT 2368 Date of Testing: 1 0/19 2 <br /> 4p:01TA, WENT <br /> Facility Address: 1399 N.MAIN ST.@ NORTHGATE,MANTECA,CA 95336r"r <br /> Facility Contact:BEN Phone:209-239-3252 ETMFff ME <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing):Elena M <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name:TANKNOLOGY INC. <br /> Technician Conducting Test: Steve Willems <br /> Credentials): 17' CSLB Contractor V ICC Service Tech. r SWRCB Tank Tester r Other(Specify) <br /> License Number(s):A <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used By: Pr, 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 PUL- <br /> Number, Stored Product, etc.) Fill 1-Direct-Grade level Fill 1-Direct-Grade level Spill Box# Spill Box# <br /> in containment sump in containment sump <br /> C Direct Bury f Direct Bury r Direct Bury r Direct Bury <br /> Bucket Installation Type: t: Contained in Sump ro Contained in Sump r Contained in Sump f Contained in Sump <br /> Bucket Diameter: 12.00 12.00 <br /> Bucket Depth: 14.50 12.75 <br /> Wait time between applying <br /> 5 min 5 min min <br /> vacuum/water and start of test min <br /> Test Start Time(Tl): 13:04:00 12:54:00 <br /> Initial Reading(Rl): 13.00 in.H2O 11.50 in.H2O <br /> Test End Time(TF) 14:04:00 13:54:00 <br /> Final Reading(RF): 13.00 in.H2O 11.50 in.1420 <br /> Test Duration(TF–TI): I hr 1 hr <br /> Change in Reading(RF–RI): 0.00 in.H2O 0.00 in.H2O <br /> Pass/Fail Threshold or Criteria: +/-0.00 +/-0.00 +/- <br /> Test Result: Pass Pass <br /> Comments-(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> hydrostatic test passes for 87 and 91,but the 5 gal capacity failed on the 91 fill. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING TI-IIS TESTING <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: 0�qs— Date: 10/19/2016 <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:2329918 <br />