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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#17647,MKT 2368(N-744) Date of Testing:7/28/2021 <br /> Facility Address: 1048 W.YOSEMITE AVE @ EL PORTEL,MANTECA,CA 95336 <br /> Facility Contact: DEALER-ANTWAN Phone:209-239-2329 <br /> Date Local Agency Was Notified of Testing: 7/2/2021 <br /> Name of Local Agency Inspector(if present during testing):Shewit Woldearegay <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name:TANKNOLOGY INC. <br /> Technician Conducting Test:Tim Elebeck <br /> Credentials): F- CSLB Contractor ICC Service Tech. r SWRCB Tank Tester r- Other(Specify) <br /> License Number(s): 8001435 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used By: Hydrostatic F 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 1 -Direct-Grade level Fill 1-Direct-Grade level <br /> C• Direct Bury G Direct Bury C Direct Bury f Direct Bury <br /> Bucket Installation Type: r Contained in Sump r Contained in Sump r Contained in Sump r Contained in Sump <br /> Bucket Diameter: 12.00 12.00 <br /> Bucket Depth: 12.00 12.00 <br /> Wait time between applying <br /> 1 min 1 min min min <br /> vacuum/water and start of test <br /> Test Start Time(Tl): 08:30:00 08:35:00 <br /> Initial Reading(Rl): 30.00 PSI 30.00 PSI <br /> Test End Time(TF): 08:31:00 08:36:00 <br /> Final Reading(RF): 30.00 PSI 30.00 PSI <br /> Test Duration(TF-Tl): 1 min 1 min <br /> Change in Reading(RF-Rl): 0.00 PSI 0.00 PSI <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 recommended follow-up for failed tests) <br /> CERTIFICATION OF TECI INICIAN 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: I`J,—.L"9 f LJ,— k Date: 7/28/2021 <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:2350909 <br />