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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 /> Facility Name: 7-ELEVEN # 17334 MKT 2368 (N-747) Date of Testing: 9/20/2019 <br /> Facility Address: 4501 N. PERSHING AVE. @ ROSEMARIE LN., STOCKTON, CA 95207 _ <br /> Facility Contact: MGR - SATBIR Phone: 209-951 -6745 <br /> Date Local Agency Was Notified of Testing : <br /> Name of Local Agency Inspector (if present during testing): Paul Nso <br /> 2 . TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY INC. <br /> Technician Conducting Test: Clint Fuhrman <br /> Credentials ) : ry CSLB Contractor r ICC Service Tech, SWRCB Tank Tester F Other (Specify) <br /> License Number(s) : 9160945 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used By : Hydrostatic Vacuum 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 /> r+' Direct Bury r Direct Bury r" Direct Bury r" Direct Bury <br /> Bucket Installation Type : (" Contained in Sump (' Contained in Sump r" Contained in Sump r Contained in Sump <br /> Bucket Diameter: 12.00 12.00 <br /> Bucket Depth: 16. 50 13 .50 <br /> Wait time between applying <br /> 1 min 1 min min min <br /> vacuum/water and start of test <br /> Test Start Time (TI): 09:05:00 09:08:00 <br /> Initial Reading (RI): 30.00 in. H2O 30.00 in. H2O <br /> Test End Time(TF): 09:06:00 09:09:00 <br /> Final Reading (RF): 30.00 in. H2O 28.00 in. H2O <br /> Test Duration(TF—TI): 1 min 1 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 : � ^ Date : 9/20/2019 <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 : 2342150 <br />