Laserfiche WebLink
' a <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 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 /> Facility Name:7-ELEVEN#17647,MKT 2368(N-744) Date of Testing:7/21/2020 <br /> Facility Address: 1048 W.YOSEMTTE AVE @ EL PORTEL,MANTECA,CA 95336 <br /> Facility Contact:DEALER-ANTWAN Phone:209-239-2329 <br /> Date Local Agency Was Notified of Testing:7/21/2020 <br /> Name of Local Agency Inspector(ifpresent during testing):UNKNOWN <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name:TANKNOLOGY INC. <br /> Technician Conducting Test:Jesus Saldivar <br /> Credentialsi: 1- CSLB Contractor ICC Service Tech. r SWRCB Tank Tester r Other(Specify) <br /> License Number(s): <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used By: r Hydrostatic r Vacuum r Other <br /> Test Equipment Used:VACUUM TEST Equipment Resolution: 0.1 gph <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 1-Direct-Grade level <br /> (: Direct Bury t: Direct Bury �' Direct Bury C` Direct Bury <br /> Bucket Installation Type: C Contained in Sump �' Contained in Sump f Contained in Sump r Contained in Sump <br /> Bucket Diameter: 12.00 12.00 <br /> Bucket Depth: 12.00 13.00 <br /> Wait time between applying <br /> vacuum/water and start of test I min 1 min mm <br /> Test Start Time(TI): 08:00:00 08:02:00 <br /> Initial Reading(Rl): 30.00 in.H2O 30.00 in.H2O <br /> Test End Time(TF): 08:01:00 08:03:00 <br /> Final Reading(RF): 30.00 in.H2O 28.00 in.H2O <br /> Test Duration(TF—TI): 1 min I min <br /> Change in Reading(RF—RI): 0.00 in.H2O -2.00 in.H2O <br /> Pass/Fail Threshold or Criteria: +/-4.00 +/-4.00 +/- <br /> Test Result: Pass Pass <br /> Comments-(include information on repairs made prior to testing, and recommended follow-up for failed tests) <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: /.41— Date: 7/21/2020 <br /> rState laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements maybe more stringent. <br /> WO:2346948 <br />