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SWRCB. January 2006 <br />Spill Bucket Testing Report Form SEP 2 8 2016 <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 locEN)AROMAENTAL HEALTH <br />DEPARTMENT <br />1. FACILITY INFORMATION <br />Facility Name: 7 -ELEVEN #19976, MKT 2368 Date of Testing: 9/19/2016 <br />Facility Address: 1399 N. MAIN ST. @ NORTHGATE, MANTECA, CA 95336 <br />Facility Contact: BEN Phone: 209-239-3252 <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (if present during testing): Present <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: TANKNOLOGY INC. <br />Technician Conducting Test: Jeffrey Crisostomo <br />Credentials] : W CSLB Contractor 170 ICC Service Tech. r SWRCB Tank Tester r Other (Specify) <br />License Number(s): <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 <br />Number, Stored Product, etc.) <br />Spill Box # Tank T4 RUL - <br />Fill 1 - Direct - Grade level <br />in containment sump <br />Spill Box # Tank T5 PUL - <br />Fill 1 - Direct - Grade level <br />in containment sump <br />Spill Box # <br />Spill Box # <br />Bucket Installation Type: <br />C' Direct Bury <br />fe Contained in Sump <br />r Direct Bury <br />10 Contained in Sump <br />r Direct Bury <br />f Contained in Sump <br />f Direct Bury <br />r Contained in Sump <br />Bucket Diameter: <br />12.00 <br />12.00 <br />Bucket Depth: <br />12.50 <br />12.50 <br />Wait time between applying <br />vacuum/water and start of test <br />15 min <br />15 min <br />min <br />min <br />Test Start Time (Tl): <br />Initial Reading (Rl): <br />Test End Time(TF): <br />Final Reading (RF): <br />Test Duration(TF—T]): <br />Change in Reading (RF—RI) : <br />Pass/Fail Threshold or Criteria:, <br />- <br />Test Result: <br />Fail <br />Fail <br />Comments - (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />91 and 87 fill spill buckets failed. Need to get fixed and re -test. <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: Date: 9/19/2016 <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: 2328115 <br />