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- FACH.YlrV INFORMATION <br />Facility Name: 7 -ELEVEN # 19976, MKT 2368 Date of Testing: 10/7/2015 <br />Facility Address: 1399 N. MAIN ST. @ NORTHGATE, MANTECA, CA 95336 <br />Facility Contact: BEN Phone: 209-239- ' <br />1 11 <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (if present during testing): andria nrT I A 2,111� <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: TANKNOLOGY INC. — NFfA'TH r1CG+gATlpCK1T <br />Technician Conducting Test: Jarrod Cooke <br />Credentialst : R CSLB Contractor ❑ ICC Service Tech. r_1 SWRCB Tank Tester r Other (Specify) <br />License Number(s): 743160 <br />txy91Pw:3,110;lDr0-1&31QUI l i0)9001CIRI <br />fest Method Used By: r Hydrostatic r Vacuum r Other <br />"Fest 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 />Direct Bury <br />49 Contained in Sump <br />% Direct Bury <br />(I Contained in Sump <br />0 Direct Bury <br />4 Contained in Sump <br />Direct Bury <br />Q, Contained in Sump <br />Bucket Diameter: <br />14.00 <br />14.00 <br />Bucket Depth: <br />12.00 <br />12.50 <br />Wait time between applying <br />vacuum/water and start of test <br />5 min <br />5 min <br />min <br />min <br />Test Start Time (Tl): <br />09:04:00 <br />09:04:00 <br />Initial Reading (RI): <br />11.75 in. <br />12.00 in. <br />Test End Time(TF): <br />10:04:00 <br />10:04:00 <br />Final Reading (RF): <br />11.75 in. <br />12.00 in. <br />Test Duration(TF–TI): <br />1 hr <br />1 hr <br />Change in Reading (RF–RI): <br />0.00 in. <br />0.00 in. <br />Pass/Fail Threshold or Criteria: <br />+/-0.00 <br />+/-0.00 <br />- <br />+/- <br />Test Result: <br />Pass <br />Pass <br />Comments - (include information on repairs made prior to tesliug, 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: CJS Date: 10/7/2015 <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: 2324217 <br />