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REC,7.3 Janua eM <br /> Spill Bucket Testing Report Form DEC 0 5 2016 <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 /> ENVIRONMENTAL HEALTH <br /> 1.FACILITY INFORMATION QFPARTMENT <br /> Facility Name:7-ELEVEN#19976,MKT 2368 Date of Testing: 11/15/2016 <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: 11/10/2016 <br /> Name of Local Agency Inspector(if present during testing): <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name:TANKNOLOGY INC. <br /> Technician Conducting Test:Brent Bowen <br /> Credentials]: r CSLB Contractor F ICC Service Tech. W SWRCB Tank Tester r Other(Specify) <br /> License Number(s):743160 <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used By: W Hydrostatic r Vacuum r Other <br /> Test Equipment Used:LAKE TEST I 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 /> l" Direct Bury r Direct Bury (" Direct Bury C' Direct Bury <br /> Bucket Installation Type: (. Contained in Sump f+" Contained in Sump r Contained in Sump r Contained in Sump <br /> Bucket Diameter: 12.00 12.00 <br /> Bucket Depth: 14.00 14.00 <br /> Wait time between applying <br /> 1 min 1 min min min <br /> vacuum/water and start of test <br /> Test Start Time(Ti): 13:10:00 13:10:00 <br /> Initial Reading(Rl): 14.00 in. 14.00 in. <br /> Test End Time(TF): 14:10:00 14:10:00 <br /> Final Reading(RO 14.00 in. 14.00 in. <br /> Test Duration(TF–T]): I hr 1 hr <br /> Change in Reading(RF–RI): 0.00 in. 0.00 in. <br /> Pass/Fail Threshold or Criteria: +/-0.25 +/-0.25 +/- <br /> Test Result: Pass Pass <br /> Comments-(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> hauled off 12 gallons for recycling. <br /> CERTIFICATION OF TECHNICIAN 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: *Py-e— Date: 11/15/2016 <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 /> W O:2329970 <br />