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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 14113, MKT 2368 Date of Testing : 9/9/2020 <br /> Facility Address : 3040 BENJAMIN HOLT DR @ GRIGSBY , STOCKTON, CA 95219 <br /> Facility Contact: STORE MANAGER Phone: 209478-3040 <br /> Date Local Agency Was Notified of Testing : 9/9/2020 <br /> Name of Local Agency Inspector (ifpresent during testing). UNKNOWN t 0 ; <br /> f I ` <br /> 2 . TESTING CONTRACTOR INFORMATION <br /> C % <br /> Company Name: TANKNOLOGY INC. <br /> Technician Conducting Test: Jesus Saldivar <br /> Credentialsl : CSLB Contractor W ICC Service Tech. r SWRCB Tank Tester ri Other (Specify) w <br /> - - — <br /> License Number(s) : <br /> 3 . SPILL BUCKET TESTING INFORMATION <br /> Test Method Used By : W Hydrostatic r Vacuum Other <br /> Test Equipment Used : LAKE TEST Equipment Resolution : 0.0625 in. <br /> Spill Box # Tank T1 Spill Box # Tank T2 <br /> Identify Spill Bucket (By Tank REGULAR - Fill 1 - Direct - SUPREME - Fill 1 - Direct - Spill Box # Spill Box # <br /> Number, Stored Product, etc.) Grade level in containment Grade level in containment <br /> sump sump <br /> Direct Bury 9Direct Bury l ' Direct Bury f Direct Bury <br /> Bucket Installation Type : t`• Contained in Sump t: Contained in Sump r Contained in Sump r Contained in Sump <br /> Bucket Diameter: 12.00 12.00 <br /> Bucket Depth : 13 .00 13 .00 <br /> Wait time between applying <br /> 5 min 5 min min min <br /> vacuum/water and start of test <br /> Test Start Time (Tl): 09:00:00 09:00:00 <br /> Initial Reading (Rl ): 13 .00 in. H2O 13 .00 in. H2O <br /> Test End Time(TF): 10:00:00 10:00:00 <br /> j Final Reading (RF): 13 .00 in. H2O 13 .00 in. H2O <br /> i <br /> Test Duration(TF—Tl): 1 hr 1 hr <br /> Change in Reading (RF—Rl ) : 0.00 in. H2O 0.00 in. H2O <br /> r <br /> Pass/Fail Threshold or Criteria: +/- 0.00 +/- 0.00 <br /> Test Result: Pass Pass <br /> Comments - (include information on repairs made prior to testing, and recoa)zmended follow- ztp 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 : 4L Date : 9/9/2020 <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 : 2346945 <br />