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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 41187 Date of Testing:9/14/2023 <br /> Facility Address: 1829 N Wilson Way,Stockton,CA 95204 <br /> Facility Contact: Phone:209-414-7328 <br /> Date Local Agency Was Notified of Testing:9/14/2023 <br /> Name of Local Agency Inspector(if present during testing):Environmental <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name:TANKNOLOGY INC. <br /> Technician Conducting Test:Brent Bowen <br /> Credentialsl: F74 CSLB Contractor F. ICC Service Tech. r SWRCB Tank Tester r Other(Specify) <br /> License Number(s):74360 <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used By: 7 Hydrostatic r Vacuum r Other <br /> Test Equipment Used:LAKE TEST 1 Equipment Resolution:0.0625 in. <br /> Identify Spill Bucket(By Tank Spill Box#Tank"1'l Spill Box#Tank T2 Spill Box#Tank T3 dsl <br /> Number, Stored Product, etc.) REGULAR-Fill I-Direct- PREMIUM-Fill I -Direct- Diesel-Fill I-Direct- Spill Box# <br /> Grade level Grade level Grade level <br /> C" Direct Bury r Direct Bury f D <br /> Direct Bury ( Direct Bury <br /> Bucket Installation Type: Ir Contained in Sump Io Contained in Sump ro Contained in Sump f Contained in Sump <br /> Bucket Diameter: 12.00 12.00 12.00 <br /> Bucket Depth: 12.00 12.00 12.00 <br /> Wait time between applying <br /> IS min 15 min IS min <br /> vacuum/water and start of test min <br /> Test Start Time(Tl): 08:40:00 08:40:00 08:40:00 <br /> Initial Reading(Rl): 10.50 in.H2O 10.00 in. 10.50 in. <br /> Test End Time(TF): 09:40:00 09:40:00 09:40:00 <br /> Final Reading(RO 10.50 in.H2O 5.00 in. 10.50 in. <br /> Test Duration(TF—TI): 1 hr I hr 1 hr <br /> Change in Reading(Rr-RI): 0.00 in.H2O -5.00 in. 0.00 in. <br /> Pass/Fail Threshold or Criteria: U-0.00 i/-0.00 4/-0.00 /- <br /> Test Result: Pass Fail Pass <br /> Comments-(include information on repairs made prior to testing, and recommendedfollow-upforfailed tests) <br /> 91 spill bucket failed spill bucket has a tear in bottom quarter of bucket visual leak. <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: *�X_ Date: 9/14/2023 <br /> IState laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements may be more stringent. <br /> WO:2362087 <br />