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SWRCOCT 2�B 6 2015 January 2006 <br /> Spill Bucket Testing Report Form p <br /> This form is intended for use by contractors performing annual testing of LIST spill containment structures. The completHOV Kh"' 11" IAL <br /> printouts from tests(if applicable),should be provided to the facility owner/operator for submittal to the local regulatory fit! , r1Fp5PT% ph <br /> 1.FACILITY INFORMATION <br /> Facility Name:7-ELEVEN#17334 MKT 2368(N-747) Date of Testing: 10/12/2015 <br /> Facility Address:4501 N.PERSHING AVE. ROSEMARIE LN.,STOCKTON,CA 95207 <br /> Facility Contact:MGR-SATBIR Phone:209-951-6745 <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:Steve Willems <br /> Credentialsi: R CSLB Connector n ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other(Specify) <br /> License Number(s):a <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used By: r' Hydrostatic r Vacuum r Other <br /> Test Equipment Used: LAKE TEST Equipment Resolution:0.0625 in. <br /> Identify Spill Bucket(By Tank Spill Box#Tank T-1 RUL- Spill Box#Tank T-2 PUL- Spill Box# Spill Box# <br /> Number,Stored Product, etc.) Fill I-Direct-Grade level Fill I-Direct-Grade level <br /> a Direct Bury A Direct Bury • Direct Bury 4 Direct Bury <br /> FB,,k,tDiatmeter: <br /> ation Type: R Contained in Sump i Contained in Sump 4 Contained in Sump 49 Contained in Sump <br /> r: 12.00 12.00 <br /> : 12.00 12.50 <br /> ween applying 5 min 5 minmin min <br /> r and start of test <br /> Test Start Time(Tt7 10:22:00 10:22:00 <br /> Initial Reading(Rt): 12.00 in.H2O 12.50 in.1120 <br /> Test End Timejf,) 11:22:00 11:22:00 <br /> Final Reading(RF): 12.00 in.H2O 12.50 in.H2O <br /> Test Duration(TF-T1): 1 hr 1 hr <br /> Change in Reading(RF-R1): 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 /> 7 hereby certify that all the innfforrmation contained in this report is true,accurate,and in full compliance with legal requirems. <br /> ent <br /> Technician's Signature: � 0�% - Date: 10/122015 <br /> 1 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:2324215 <br />