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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 38616 Date of Testing: 8/4/2025 <br /> Facility Address:601 Carolyn Weston Blvd, Stockton,CA 95206 <br /> Facility Contact: Phone:----- <br /> Date Local Agency Was Notified of Testing: 8/4/2025 <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: F CSLB Contractor F ICC Service Tech. F SWRCB Tank Tester F Other(Specify) <br /> License Numbcr(s): <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used By: F 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 Tl RUL. Spill Box#Tank T2 PREM. Spill Box#Tank T3 DSL <br /> Number, Stored Product, etc) REGULAR-Fill 1-Direct- PREMIUM-Fill 1-Direct- Diesel-Fill 1-Direct- Spill Box# <br /> Grade level Grade level Grade level <br /> rDirect Bury r Direct Bury r Direct Bury r Direct Bury <br /> Bucket Installation Type: ro Contained in Sump ro Contained in Sump I* Contained in Sump r Contained in Sump <br /> Bucket Diameter: 12.00 12.00 12.00 <br /> Bucket Depth: 16.00 16.00 16.00 <br /> Wait time between applying <br /> vacuum/water and start of test 5 min 5 min 5 min min <br /> Test Start Time(Ti): 11:00:00 11:00:00 11:00:00 <br /> Initial Reading(Rl): 16.00 in.H2O 16.00 in.H2O 16.00 in.H2O <br /> Test End Time(TF): 12:00:00 12:00:00 12:00:00 <br /> Final Reading(RF): 16.00 in.H2O 16.00 in.H2O 16.00 in.H2O <br /> Test Duration(TF—TI): 1 hr 1 hr 1 hr <br /> Change in Reading(RF—Rl): 0.00 in.H2O 0.00 in.H2O 0.00 in.H2O <br /> Pass/Fail Threshold or Criteria: +/-0.00 +/-0.00 +/-0.00 +/- <br /> Test Result: Pass Pass Pass <br /> Comments-(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> CERTIFICATION OF TECIINICIAN 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: Date: 8/4/2025 <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:2383364 <br />