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SWRCB, January 2006 <br /> Spill Bucket Testing Report Form <br /> forn <br /> This form is intendedfor use by contractor�eet.fovided to the facilitesting <br /> ry owner�operspill <br /> ato�foarnment szibmittahtotthe locaThe <br /> l regu�ator� agency.�d <br /> printouts from tests (if applicable), shoal p <br /> 1 . FACILITY INFORMATION <br /> Date of Testing: 9/2/2020 <br /> Facility Name: 7-ELEVEN # 199767 MKT 2368 <br /> Facility Address: 1399 N. MAIN ST. @ NORTHGATE, MANTECA, CA 95336 Phone: 209-239-3252 <br /> Facility Contact: BEN <br /> Date Local Agency Was Notified of Testing: 8/ 13/2020 <br /> Name of Local Agency Inspector (if present during testing): San Joaquin Env Inspector <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY INC. <br />€ Technician Conducting Test: Clint Fuhrman <br /> Credentials ) : rCSLB Contractor ii i1i WIN lii�: ICC Service Tech. � BI oms <br /> Tank Tester r Other (Specify) <br /> License Number(s) : 9160945 <br /> 3 . SPILL BUCKET TESTING INFORMATION Other <br /> (v% Hydrostatic Vacuum <br /> Test Method Used By : Equipment Resolution: 0.0625 in. <br /> Test Equipment Used: LAKE TEST <br /> Spill Box # Tank Spill Box # Tank <br /> Identify Spill Bucket (By Tank T4:UNLEADED RUL - Fill 1 TS :PREMIIJM PUL - Fill l - <br /> Spill Box # Spill Box # <br /> Number, Stored Product, etc.) - Direct - Grade level in Direct - Grade level in <br /> containment sump containment sump <br /> r` Direct Bury f Direct Bury (' Direct Bury <br /> C` Direct Bury (" Contained in Sump <br /> Bucket Installation Type : r+ Contained in Sump re Contained in Sump r Contained in Sump <br /> Bucket Diameter: <br /> 12.00 12.00 <br /> 00 16.00 <br /> Bucket Depth: 16. min <br /> Wait time between applying 5 min 5 min mm <br /> vacuum/water and start of test 09: 16:00 <br /> Test Start Time (Tl): 09: 15 :00 <br /> Initial Reading (Rl): <br /> 15 .00 in. 15 .00 in. <br /> Test End Time(TF): <br /> 10: 15 :00 10: 16:00 <br /> 15 .00 in. 15.00 in. <br /> Final Reading (RF): <br /> 1 hr 1 hr <br /> Test Duration(TF—Tl): <br /> 0.00 in. 0.00 in. <br /> Change in Reading (RF—Rl) : <br /> Pass/Fail Threshold or Criteria: <br /> +/- 0.00 +/- 0.00 <br /> Test Result: <br /> Pass Pass <br /> Comments - (include information on repairs made prior to testing, and r•econunended follow- up for failed tests) <br /> CERTIFICATION OF TECHNICIAN 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 /> Date: 9/2/2020 <br /> Technician' s Signature : <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: 2346950 <br />