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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 farm 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 # 19976, MKT 2368 Date of Testing: 9/5/2019 <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 : <br /> Name of Local Agency Inspector (Ifpresent during testing): <br /> 2 . TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY INC. <br /> - <br /> - <br /> Technician Conducting Test: Jarrod Cooke <br /> - <br /> Credentialsi : r� CSLB Contractor ' 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 Vacitun Other <br /> Test Equipment Used : LAKE TEST Equipment Resolution : 0.0625 in. <br /> Spill Box # Tank Spill Box # Tank <br /> Identify Spill Bucket (By Tank T4:UNLEADED RUL - Fill I T5 :PREMIUM PUL - Fill 1 - Spill Box # Spill Box # <br /> Number, Stored Product, etc) - Direct - Grade level in Direct - Grade level in <br /> containment sump containment sump <br /> (" Direct Bury r Direct Bury f Direct Bury r Direct Bury <br /> Bucket Installation Type : (: Contained in Sump C+ Contained in Sump r Contained in Sump r Contained in Sump <br /> Bucket Diameter: 14.00 14.00 <br /> Bucket Depth : 13.00 13 .00 <br /> Wait time between applying 5 min 5 min min min <br /> vacuum/water and start of test <br /> Test Start Time (TI): 09:03 :00 09:03 :00 <br /> Initial Reading (RI): 12.00 in. 13 .00 in. <br /> Test End Time(TF): 10:03 :00 10:03 :00 <br /> Final Reading (RF): 12.00 in. 13 .00 in. <br /> Test Duration(TF—TI): I hr 1 hr <br /> Change in Reading (RF—RI) : 0.00 in. 0.00 in. <br /> Pass/Fail Threshold or Criteria: +/" 0600 +/- 0.00 +/- +/- <br /> Test Result: Pass Pass <br /> Comments - (include information on repairs made prior to testing, and reeomnrer7ded follow-irp for failedes ) 4 <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTIiN, E y. "- <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 : 1� r: Date : 9/5/2019 <br /> 1 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 : 2342153 <br />