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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 /> FacilityName: 7-ELEVEN # 17647, MKT 2368 (N-744) Date of Testing : 7/9/2019 <br /> Facility Address: 1048 W. YOSEMITE AVE @ EL PORTEL, MANTECA, CA 95336 <br /> Facility Contact: DEALER-ANTWAN Phone: 209-239-2329 <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: Jarrod Cooke <br /> Credentials ) : r' CSLB Contractor F ICC Service Tech. r' SWRCB Tank Tester Other (Specify) <br /> License Number(s) : 8155550 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used By : Hydrostatic 17 Vacuum Other <br /> Test Equipment Used : LAKE TEST Equipment Resolution : 0.0625 in. <br /> Identify Spill Bucket (By Tank Spill Box # Tank T- 1 RUL - Spill Box # Tank T-2 PUL - Spill Box # Spill Box # <br /> Number, Stored Product, etc.) Fill I - Direct - Grade level Fill I - Direct - Grade level <br /> r: Direct Bury r: Direct Bury r Direct Bury r` Direct Bury <br /> Bucket Installation Type : (^ Contained in Sump r" Contained in Sump r~ Contained in Sump r" Contained in Sump <br /> Bucket Diameter: 14.00 14.00 <br /> Bucket Depth : 12.00 12.50 <br /> j Wait time between applying <br /> vacuum/water and start of test 5 min 5 min min min <br /> Test Start Time (TI): 09: 10:00 09: 10:00 <br /> I Initial Reading (RT): 11 .00 in. 11.75 in. <br /> Test End Time(TF): 10: 10:00 10: 10:00 <br /> Final Reading (RF): 11 .00 in. 11 .75 in. <br /> Test Duration(TF—TI): 1 hr 1 hr <br /> s <br /> Change in Reading (RF—RI) : 0.00 in. 0.00 in. <br /> I 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 reconunended follow-up for•failed tests) <br /> 4 <br /> i <br /> CERTIFICATION OF TECENICIAN 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 : b Date : 7/9/2019 <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 : 2341089 <br /> I <br />