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�- o RECE��,9JD <br /> Spill Bucket Testing Report Form OCT 17 2016 <br /> This form is intended for use by contractors performing annual testing of UST spill containment structures. The completedform and <br /> printouts from tests(if applicable), should be provided to the facility owner/operator for submittal to the local <br /> re Ilator ENTAL HEALTH <br /> 1.FACILITY INFORMATION DEPARTMENT <br /> Facility Name:7-ELEVEN#17334 MKT 2368(N-747) Date of Testing: 10/5/2016 <br /> Facility Address:4501 N.PERSHING AVE.g 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(ifpresent during testing):victoria <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name:TANKNOLOGY INC. <br /> Technician Conducting Test: Steve Willems <br /> Credentialst: P' CSLB Contractor Pr ICC Service Tech. r SWRCB Tank Tester I" 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-I RUL- Spill Box#Tank T-2 PUL- Spill Box# Spill Box# <br /> .Number, Stored Product, etc.) Fill l-Direct-Grade level Fill 1 -Direct-Grade level <br /> r- Direct Bury IT Direct Bury (' Direct Bury t' Direct Bury <br /> Bucket Installation Type: IS Contained in Sump r Contained in Sump f Contained in Sump r Contained in Sump <br /> Bucket Diameter: 12.00 12.00 <br /> Bucket Depth: 16.50 15.00 <br /> Wait time between applying <br /> vacuum/water and start of test 5 min 5 min ruin min <br /> Test Start Time(Tl): 10:30:00 10:30:00 <br /> Initial Reading(RI): 15.50 in.H2O 14.00 in.H2O <br /> Test End Time(TF): 11:30:00 11:30:00 <br /> Final Reading(RF): 15.50 in.H2O 14.00 in.H2O <br /> Test Duration(TF-TI): 1 hr 1 hr <br /> Change in Reading(RF-RI): 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 /> 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: 1i'�R2. Date: 10/52016 <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:2328543 <br />