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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 for submittal to the local regulatory agency. <br /> 1.FACILITY INFORMATION <br /> Facility Name:7-ELEVEN#19976,MKT 2368 Date of Testing:9/17/2018 <br /> Facility Address: 1399 N.MAIN ST.@ NORTHGATE,MANTECA,CA 95336 <br /> Facility Contact:BIN Phone:209-239-3252 <br /> Date Local Agency Was Notified of Testing:9/4/2018 <br /> Name of Local Agency Inspector(if present during testing):zuna barker <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name:TANKNOLOGY INC. <br /> Technician Conducting Test:Jarrod Cooke <br /> Credentials): r7 CSLB Contractor Pr ICC Service Tech. r SWRCB Tank Tester r Other(Specify) <br /> License Number(s):8155550 <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used By: W Hydrostatic r Vacuum r Other <br /> Test Equipment Used:LAKE TEST Equipment Resolution:0.0625 in. <br /> Spill Box#Tank Spill Box#Tank <br /> Identify Spill Bucket(By Tank T4:UNLEADED RUL-Fill 1 T5:PREMRJM PUL-Fill 1- Spill Box# Spill Box# <br /> Number, Stored Product, etc) -Direct-Grade level in Direct-Grade level in <br /> containment sump containment sump <br /> (" Direct Bury r Direct Bury (' Direct Bury r Direct Bury <br /> Bucket Installation Type: (: Contained in Sump 0 Contained in Sump l' Contained in Sump ( Contained in Sump <br /> Bucket Diameter: 14.00 14.00 <br /> Bucket Depth: 14.50 15.00 <br /> Wait time between applying 15 min 15 min min min <br /> vacuum/water and start of test <br /> Test Start Time(Tl): 09:44:00 09:44:00 <br /> Initial Reading(Rl): 13.75 in. 14.50 <br /> Test End Time(TF): 10:44:00 10:44:00 <br /> Final Reading(RO 13.75 in. 14.50 <br /> Test Duration(TF—TI): 1 hr 1 hr <br /> Change in Reading(RF—Rl): 0.00 in. 0.00 <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 inf/oorr-m�at�ion contained in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: CJS Date: 9/17/2018 <br /> 1State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements may be more stringent. <br /> WO:2337558 <br />