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t 0 <br /> 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 compl e r n F.I V E L <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 FEB 2 7 2015 <br /> Facility Name:7 ELEVEN 35355 Date of Testing:2/20/2 <br /> Facility Address:3202 W HAMMER LANE,STOCKTON,CA 95209 r ry r>�ta9T�A �s <br /> Facility Contact:MANAGER Phone:209-951-3345 <br /> Date Local Agency Was Notified of Testing:2/20/2015 <br /> Name of Local Agency Inspector(if present during testing):enviormental <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name:TANKNOLOGY INC. <br /> Technician Conducting Test:Brent Bowen <br /> Credentials: W CSLB Contractor r—. ICC Service Tech. r SWRCB Tank Tester r— Other(Specify) <br /> License Number(s):743160 <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used By: Hydrostatic r7 vacuum r— Other <br /> Test Equipment Used:LAKE TEST Equipment Resolution:0.0625 in. <br /> Identify Spill Bucket(By Tank Spill Box#Tank Tl:RUL- Spill Box#Tank T2:PUL- Spill Box#Tank T3:Diesel- <br /> Number, Stored Product, etc.) Fill 1-Direct-Grade level Fill I -Direct-Grade level Fill 1-Direct-Grade level Spill Box# <br /> in containment sump in containment sump in containment sump <br /> C Direct Bury r Direct Bury f Direct Bury f Direct Bury <br /> Bucket Installation Type: ro Contained in Sump f«' Contained in Sump t+ Contained in Sump r Contained in Sump <br /> Bucket Diameter: 24.00 24.00 24.00 <br /> Bucket Depth: 24.00 24.00 24.00 <br /> Wait time between applying <br /> 1 min 1 min 1 min min <br /> vacuum/water and start of test <br /> Test Start Time(Tl): 09:00:00 09:00:00 09:00:00 <br /> Initial Reading(Rt): 23.00 in. 23.00 in. 23.00 in. <br /> Test End Time(TF): 10:00:00 10:00:00 10:00:00 <br /> Final Reading(RF): 23.00 in. 23.00 in. 23.00 in. <br /> Test Duration(TF—T,): 1 hr 1 hr 1 hr <br /> Change in Reading(RF—RI): 0.00 in. 0.00 in. 0.00 in. <br /> Pass/Fail Threshold or Criteria: +/-0.25 +/-0.25 +/-0.25 +/- <br /> Test:Rswlt; I'ass777771. Pass Pais <br /> COmmeritS-(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> 30 gallons of test water taken off site <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: �' Date: 2/20/2015 <br /> 1State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements may be more stringent. <br /> WO:2321635 <br />