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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 jar submittal to the local regulatory agency. <br /> 1.FACILITY INFORMATION <br /> Facility Name:7-ELEVEN#17334 MKT 2368(N-747) Date of Testing: 10/3/2017 <br /> Facility Address:4501 N.PERSHNG AVE.@ ROSEMARIE LN.,STOCKTON,CA 95207 <br /> Facility Contact:MGR-SATBIR Phone:209-951-6745 <br /> Date Local Agency Was Notified of Testing: 10/3/2017 <br /> Name of Local Agency Inspector(ifpresent during testing):enviormental <br /> 2.TESTING CONTRACTOR INFORMATI N <br /> Company Name:TANKNOLOGY INC. ou 16 2017 <br /> Technician Conducting Test:Brent Bowen <br /> Credentialsl: r CSLB Contractor r ICC Service Tech. r SWRCB Tank Tester C Other( TH <br /> License Number(s):743160 oppARThAeNT <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 Bax# <br /> Number, Stored Product, etc) Fill I -Direct-Grade level Fill 1-Direct-Grade level <br /> r Direct Bury IT Direct Bury r Direct Bury f Direct Bury <br /> Bucket Installation Type: (a:. 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: 14.50 14.00 <br /> Wait time between applying <br /> vacuum/water and start of test 1 min 1 min min min <br /> Test Start Time(T1): 09:00:00 09:00:00 <br /> Initial Reading(R1): 14.00 in. 14.00 in. <br /> Test End Time(TF): 10:00:00 10:00:00 <br /> Final Reading(RF): 14.00 in. 12.00 in. <br /> Test Duration(TF-TI): 1 hr 1 hr <br /> Change in Reading(Rl—RI): 0.00 in. -2.00 in. <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 failed turned into office. <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: X Date: 10/3/2017 <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:2332615 <br />