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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) I Date of Testing:7/25/2024 <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: <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:TANKNOLOGY INC. <br /> Technician Conducting Test:Edwin Pineda <br /> Credentials l: R CSLB Contractor r— ICC Service Tech. r— SWRCB Tank Tester r— Other(Specify) <br /> Licensc Number(s):743160 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used By: 1W Hydrostatic F Vacuum F Other <br /> Test Equipment Used:LAKE TEST Equipment Resolution:0.0625 in. <br /> Identify Spill Bucket(By Tank Spill Box#Tank Regular Spill Box#Tank Premium <br /> Number, Stored Product, etc.) RUL-Fill l-Direct-Grade PUL-Fill I-Direct-Grade Spill Box# Spill Box# <br /> level level <br /> C: Direct Bury C Direct Bury r Direct Bury C Direct Bury <br /> Bucket Installation Type: r Contained in Sump C Contained in Sump r Contained in Sump C Contained in Sump <br /> Bucket Diameter: 12.00 12.00 <br /> Bucket Depth: 14.00 14.00 <br /> Wait time between applying 10 min 10 min min min <br /> vacuum/water and start of test <br /> Test Start Time(TI): 09:00:00 09:00:00 <br /> Initial Reading(RI): 13.00 in.1420 13.00 in.H2O <br /> Test End Time(TF): 10:00:00 10:00:00 <br /> Final Reading(RF): 13.00 in.H2O 13.00 in.H2O <br /> Test Duration(TF—TI): 1 hr I hr <br /> Change in Reading(RF—RI): 0.00 in.H2O 0.00 in.H2O <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 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: DA "t;A�` '��`' Date: 7/25/2024 <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:2369378 <br />