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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: 7/9/2025 <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: 7/2/2025 <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:TANKNOLOGY INC. <br /> Technician Conducting Test: Carlos Zaragoza <br /> Credentials): F CSLB Contractor F ICC Service Tech. F- SWRCB Tank Tester F Other(Specify) <br /> License Number(s): <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used By: F Hydrostatic r- 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 1-Direct-Grade PUL-Fill 1-Direct-Grade Spill Box# Spill Box# <br /> level level <br /> ro Direct Bury r• Direct Bury r` Direct Bury r 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: 14.00 14.00 <br /> Wait time between applying <br /> 5 min 5 min min min <br /> vacuum/water and start of test <br /> Test Start Time(Tl): 09:00:00 09:05:00 <br /> Initial Reading(Rl): 12.00 in.H2O 12.00 in.H2O <br /> Test End Time(Tp): 10:00:00 10:05:00 <br /> Final Reading(RF): 12.00 in.H2O 12.00 in.H2O <br /> Test Duration(TF—TI): 1 hr 1 hr <br /> Change in Reading(Rp—Rl): 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 TECB NICIAN 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: tr Date: 7/9/2025 <br /> t 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:2384587 <br />