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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:Rebel Store#0376 Date of Testing: 1/24/2024 <br /> Facility Address:3725 Tracy Blvd,Tracy,CA 95304 <br /> Facility Contact: Phone:209-834-1096 <br /> Date Local Agency Was Notified of Testing: 1/17/2024 <br /> Name of Local Agency Inspector(if present during testing):UNKNOWN <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:TANKNOLOGY INC. <br /> Technician Conducting Test:Jesus Saldivar <br /> Credentialsl: r CSLB Contractor rv-1 ICC Service Tech. r SWRCB Tank Tester r Other(Specify) <br /> License Number(s): <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used By: P7 Hydrostatic r vacuum 1 Other <br /> Test Equipment Used:LAKE TEST Equipment Resolution:0.0625 in. <br /> Spill Box#Tank T-187 Spill Box#Tank T-2 87 Spill Box#Tank T-3 91 Spill Box#Tank T4 DIESEL <br /> Identify Spill Bucket(By Tank REGULAR-Fill l-Direct- REGULAR-Fill 1 -Direct- PREMIUM-Fill 1 -Direct- Diesel-Fill I -Direct- <br /> Number,Stored Product, etc.) Grade level in containment Grade level in containment Grade level in containment Grade level in containment <br /> sump sump sump sump <br /> l" Direct Bury r Direct Bury f Direct Bury r' Direct Bury <br /> Bucket Installation Type: (? Contained in Sump r Contained in Sump f: Contained in Sumpp <br /> Contained in Sum <br /> Bucket Diameter: 12.00 12.00 12.00 12.00 <br /> Bucket Depth: I x.00 15.00 15.00 15.00 <br /> Wait time between applying <br /> 5 min 5 min 5 min 5 min <br /> vacuum/water and start of test <br /> Test Start Time(TI): 07:40:00 07:40:00 07:40:00 07:40:00 <br /> Initial Reading(RI): 15.00 in.H2O 15.00 in.H2O 15.00 in.H2O 15.00 in.H2O <br /> Test End Time(TF): 08:40:00 08:40:00 08:40:00 08:40:00 <br /> Final Reading(RF): 15.00 in.H2O 15.00 in.H2O 15.00 in.H2O 15.00 in.H2O <br /> Test Duration(TF—TI): 1 hr l hr I hr I hr <br /> Change in Reading(RF—Rt): 0.00 in.H2O 0.00 in.H2O 0.00 in.H2O 0.00 in.H2O <br /> Pass/Fail Threshold or Criteria: +/-0.00 1 i-0.00 1/-0.00 /-0.00 <br /> Test Result: Pass 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 /> 1 hereby certify that all the information contained in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: '1.41-- Date: 1/24/2024 <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:2363950 <br />