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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:7/12/2018 <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:6/28/2018 <br /> Name of Local Agency Inspector(if present during testing):unknown <br /> 2.TESTING CONTRACTOR INFORMATION RECEIVED <br /> Company Name:TANKNOLOGY INC. <br /> Technician Conducting Test:Tim Elebeck 717 23 1' <br /> Credentialsl: r CSLB Contractor P-0 ICC Service Tech. r SWRCB Tank Tester r Other(Specify) <br /> License Number(s):8001435 <br /> T <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used By: r Hydrostatic r— vacuum r Other <br /> Test Equipment Used:LAKE TEST I Equipment Resolution:0.0625 in. <br /> Identify Spill Bucket(By Tank Spill Box#Tank T-I RUL- Spill Box#Tank T-2 PUL- Spill Box# Spill Box# <br /> Number,Stored Product, etc.) Fill I -Direct-Grade level Fill 1-Direct-Grade level <br /> Co Direct Bury Direct Bury �` Direct Bury C' Direct Bury <br /> Bucket Installation Type: r Contained in Sump �' Contained in Sump 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(TI): 09:30:00 09:30:00 <br /> Initial Reading(RI): 13.25 in.H2O 13.00 in.H2O <br /> Test End Time(TF): 10:30:00 10:30:00 <br /> Final Reading(RF): 13.25 in.H2O 11.50 in.H2O <br /> Test Duration(TF—TI): I hr 1 hr <br /> Change in Reading(RF—RI): 0.00 in.H2O -1.50 in.H2O <br /> Pass/Fail Threshold or Criteria: +/-0.00 +/-0.00 +/- <br /> Test Result: Pass Fail <br /> Comments-(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> 91 bucket failed <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: -`�' " "� L""ck Date: 7/12/2018 <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:2336697 <br />