Laserfiche WebLink
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 />� r.��nn imV iNCl1DMATT(1N <br />Facility Name: 7 -ELEVEN # 17647, MKT 2368 (N-744) 1 Date of Testing: 7/13/2017 <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 (ifpresent during testing): �" <br />2. TESTING CONTRACTOR INFORMATION G "I ZU11 <br />Company Name: TANKNOLOGY INC. <br />Technician Conducting Test: Jesus Saldivar ENVIRONMENTAL HEALT <br />Credentials): r CSLB Contractor r ICC Service Tech. r SWRCB Tank Tester r Other (Specify) DEPARTMENT <br />License Number(s): <br />i. CPTT.I . RTTCKF.T TF.STtNG INFORMATION <br />Test Method Used By: r I Ivdrostatic FV Vacuum Other <br />Test Equipment Used: VACUUM TEST Equipment Resolution: 0.1 gph <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />Spill Box # Tank T-1 RUL - <br />Fill l - Direct - Grade level <br />Spill Box # Tank T-2 PUL - <br />Fill I - Direct - Grade level <br />Spill Box # <br />Spill Box # <br />Bucket Installation Type: <br />r Direct Bury <br />r Contained in Sump <br />r* Direct Bury <br />r Contained in Sump <br />r Direct Bury <br />r Contained in Sump <br />r Direct Bury <br />r Contained in Sump <br />Bucket Diameter: <br />11.50 <br />11.50 <br />Bucket Depth: <br />14.00 <br />14.00 <br />Wait time between applying <br />vacuum/water and start of test <br />1 min <br />5 min <br />min <br />min <br />Test Start Time (TI): <br />09:00:00 <br />09:01:00 <br />Initial Reading (RI): <br />30.00 in. H2O <br />14.00 in. H2O <br />"fest End Time(TF): <br />09:01:00 <br />10:01:00 <br />Final Reading (RF): <br />30.00 in. H2O <br />14.00 in. H2O <br />Test Duration(TF—Tt} <br />I min <br />1 hr <br />Change in Reading (RF—RI) : <br />0.00 in. H2O <br />0.00 in. H2O <br />Pass/Fail Threshold or Criteria: <br />+/-4.00 <br />+/-0.00 <br />+/- <br />+/- <br />Test Result: <br />Pass <br />Pass <br />Comments - (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />COULDNT PULL VACUUM ON PREM SPILL BUCKET SO TESTED HYDROSTAIC AND PASSED <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />/ hereby certify that all the information contained in this report is true, accurate, and in full compliance with legal requirements. <br />Technician's Signature: d°"" �e&_ Date: 7/13/2017 <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: 2331618 <br />