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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 420632,MKT 2368 Date of Testing: 12/13/2022 <br /> Facility Address:4627 DA VINCI DR @ MARCH LN,STOCKTON,CA 95207 <br /> Facility Contact:MGR-SATBIR(PTO#N-748) Phone:209-952-3543 <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 l: r CSLB Contractor rv— ICC Service Tech. r SWRCB Tank Tester r Other(Specify) <br /> Licensc Number(s): 8155550 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used By: FV- Hydrostatic F Vacuum F Other <br /> Test Equipment Used:LAKE TEST Equipment Resolution:0.0625 in. <br /> Spill Box#Tank 3 Spill Box#Tank 4 Spill Box#Tank 5 Diesel- <br /> Identify Spill Bucket(By Tank REGULAR-Fill 1-Direct- PREMIUM-Fill 1-Direct- Fill 1-Direct-Grade level Spill Box# <br /> Number, Stored Product, etc) Grade level in containment Grade level in containment <br /> in containment sump <br /> sump sump <br /> Bucket Installation Type: rDirect Bury C Direct Bury r Direct Bury C Direct Bury <br /> C: Contained in Sump C Contained in Sump C: Contained in Sump C Contained in Sump <br /> Bucket Diameter: 14.00 14.00 14.00 <br /> Bucket Depth: 15.00 15.00 15.00 <br /> Wait time between applying <br /> 5 min 5 min 5 min min <br /> vacuum/water and start of test <br /> Test Start Time(TI): 09:09:00 09:09:00 09:09:00 <br /> Initial Reading(RI): 13.50 in. 13.50 in. 14.00 in. <br /> Test End Time(TF): 10:09:00 10:09:00 10:09:00 <br /> Final Reading(RF): 13.50 in. 13.50 in. 14.00 in. <br /> Test Duration(TF—TI): 1 hr 1 hr 1 hr <br /> Change in Reading(RF—RI): 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 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: b�� Date: 12/13/2022 <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:2358001 <br />