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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 41342 Date of Testing:4/20/2022 <br /> Facility Address: 1233 E Dr.Martin Luther King Jr Blvd,Stockton,CA 95205 <br /> Facility Contact: Phone:- <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:TANKNOLOGY INC. <br /> Technician Conducting Test:Jarrod Cooke <br /> Credentials): r- CSLB Contractor ICC Service Tech. T- SWRCB Tank Tester F Other(Specify) <br /> License Number(s): 8155550 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used By: F` Hydrostatic r- Vacuum Other <br /> Test Equipment Used:LAKE TEST Equipment Resolution:0.0625 in. <br /> Spill Box#Tank Regular Spill Box#Tank Premium Spill Box#Tank T-3 <br /> Identify Spill Bucket(By Tank REGULAR-Fill 1-Direct- PREMIUM-Fill 1-Direct- DIESEL Diesel-Fill 1- Spill Box# <br /> Number,Stored Product, etc) Grade level in containment Grade level in containment Direct-Grade level in <br /> sump sump containment sump <br /> C" Direct Bury r Direct Bury C Direct Bury r Direct Bury <br /> Bucket Installation Type: (o Contained in Sump fo Contained in Sump fo Contained in Sump r Contained in Sump <br /> Bucket Diameter: 14.00 14.00 14.00 <br /> Bucket Depth: 13.00 13.00 13.00 <br /> Wait time between applying <br /> 5 min 5 min 5 min min <br /> vacuum/water and start of test <br /> Test Start Time(Tl): 09:36:00 09:36:00 09:36:00 <br /> Initial Reading(Rl): 11.50 in. 12.00 in. 11.50 in. <br /> Test End Time(TF): 10:36:00 10:36:00 10:36:00 <br /> Final Reading(RF): 11.50 in. 12.00 in. 11.50 in. <br /> Test Duration(TF-TI): 1 hr 1 hr 1 hr <br /> Change in Reading(RF-Rl): 0.00 in. 0.00 in. 0.00 in. <br /> Pass/Fail Threshold or Criteria: +/-0.00 +/-0.00 +/-0.00 +/- <br /> Test Result: Pass Pass Pass <br /> Comments-(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> CERTIFICATION OF TECB NICIAN 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: b �� Date: 4/20/2022 <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:2356688 <br />