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 /> 1.FACILITY INFORMATION <br /> Facility Name:7-ELEVEN#17334 MKT 2368(N-747) Date of Testing: 10/20/2017 <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): fE <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name:TANKNOLOGY INC. 96; 9 7 9R17 <br /> Technician Conducting Test:Jesus Saldivar <br /> Credentialsl: r CSLB Contractor W ICC Service Tech. r SWRCB Tank Tester r Other(S ecify) <br /> License Number(s): LJFF -o <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used By: r Hydrostatic r Vacuum r Other <br /> Test Equipment Used:VACUUM"FEST I Equipment Resolution:0.1 gph <br /> Identify Spill Bucket(By Tank Spill Box#Tank T-2 PUL- Spill Box# Spill Box# Spill Box d <br /> :Number,Stored Product, etc.) F81 1 -Direct-Grade level <br /> G Direct Bury r Direct Bury r Direct Bury f Direct Bury <br /> 6tae <br /> t Installation Type: f Contained in Sump r Contained in Sump r Contained in Sump r Contained in Sump <br /> t Diameter: 12.00 <br /> t Depth: 14.00 <br /> ime between applying 1 min min min min <br /> m/water and start of test <br /> tart Time(T1): 06:30:00 <br /> Reading(R1): 30.00 in.H2O <br /> nd Time(TF} 06:31:00 <br /> eading(RF): 29.00 m.H2O <br /> uration(TF-TI): 1 min <br /> e in Reading(RF-Rt): -1.00 in.H2O <br /> Pass/Fail Threshold or Criteria: +/-4.00 +/- <br /> Test Result: 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 /> J hereby certify that all the information contained in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: J""eew- Date: 10202017 <br /> [State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements maybe more stringent. <br /> WO:2333916 <br />