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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 Natne: 7 -ELEVEN #19976, MKT 2368 <br />Date of Testing: 12/15/2022 <br />Facility Address: 1399 N. MAIN ST. @ NORTHGATE, MANTECA, CA 95336 <br />Facility Contact: BIN Phone: 209-239-3252 <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 />TestMethod Used By: F` Hydrostatic Vacuum Other <br />Test Equipment Used: LAKE TEST Equipment Resolution: 0.0625 in. <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc) <br />Spill Box # Tank <br />T4:UNLEADED RUL - Fill 1 <br />- Direct - Grade level in <br />containment sump <br />Spill Box # Tank <br />T5:PREMILIM PUL - Fill 1- <br />Direct - Grade level in <br />containment sump <br />Spill Box # <br />Spill Box # <br />Bucket Installation Type: <br />C" Direct Bury <br />(o Contained in Sump <br />r Direct Bury <br />fo Contained in Sump <br />C Direct Bury <br />r Contained in Sump <br />r Direct Bury <br />r Contained in Sump <br />Bucket Diameter: <br />14.00 <br />14.00 <br />Bucket Depth: <br />14.00 <br />14.00 <br />Wait time between applying <br />vacuum/water and start of test <br />5 min <br />5 min <br />min <br />min <br />Test Start Time (Tl): <br />09:00:00 <br />09:00:00 <br />Initial Reading (Rl): <br />13.25 in. <br />13.75 in. <br />Test End Time(TF): <br />10:00:00 <br />10:00:00 <br />Final Reading (RF): <br />13.25 in. <br />13.75 in. <br />Test Duration(TF-TI): <br />1 hr <br />1 hr <br />Change in Reading (RF-Rl) : <br />0.00 in. <br />0.00 in. <br />Pass/Fail Threshold or Criteria: <br />+/-0.00 <br />+/-0.00 <br />+/- <br />+/- <br />Test Result: <br />Pass <br />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 �� <br />Date: 12/15/2022 <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: 2359470 <br />