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SWRCB, January 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intended for use by contractors per forting annual testing of UST spill containment structures. The completed form and <br /> pr•intotits 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 #20632, MKT 2368 Date of Testing: 2/5/2020 <br /> Facility Address: 4627 DA VINCI DR @ MARCH LN, STOCKTON, CA 95207 <br /> Facility Contact: MGR - SATBIR (PTO# N-748) Phone 209-952-3543 <br /> Date Local Agency Was Notified of Testing: 1 /29/2020 <br /> Name of Local Agency Inspector (ifpresent during testing): UNKNOWN VVI <br /> 2 . TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY INC. <br /> Technician Conducting Test: Jesus Saldivar 7114 <br /> Credentials ) : CSLB Contractor r ICC Service Tech. r SWRCB Tank Tester � Other (Specif}) " <br /> tkI �4 <br /> License Number(s) : <br /> 3 . SPILL BUCKET TESTING INFORMATION <br /> Test Method Used By : Hydrostatic F Vacuurn Other <br /> Test Equipment Used: Equipment Resolution : <br /> Identify Spill Bucket (By Tank Spill Box # Tank T1 :RUL Spill Box # Tank T2 :PUL <br /> REGULAR - Fill I - Direct - PUL - Fill 1 - Direct - Grade Spill Box # Spill Box # <br /> Number, StoredProduct, etc.) Grade level level <br /> t+ Direct Bury �+` Direct Bury r Direct Bury (` Direct Bury <br /> Bucket Installation Type : 1" Contained in Sump Contained in Sump �" Contained in Sump f Contained in Sump <br /> Bucket Diameter: 12.00 12.00 <br /> Bucket Depth : 13 .00 13 .00 <br /> Wait time between applying <br /> 1min1 min min min <br /> vacuum/water and start of test <br /> Test Start Time (TI): 08:00:00 08 :02:00 <br /> Initial Reading (RI): 30.00 in. H2O 30.00 in. H2O <br /> Test End Time(TF): 08 :01 :00 08:03 :00 <br /> Final Reading (RF): 30.00 in. H2O 28.00 in, H2O <br /> Test Duration(TF—TI): 1 min I nun <br /> Change in Reading (RF—RI ) : 0.00 in. H2O -2.00 in. H2O <br /> Pass/Fail Threshold or Criteria: +/- 4.00 +/- 4,00 +/- +/- <br /> Test Result: Pass Pass <br /> Comments - (include information on repairs made prior to testing, and recornnrerrded follow-tip for failed tests) <br /> CERTIFICATION OF TECIINICIAN 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 : e « Date : 2/5/2020 <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 : 2344044 <br /> i <br />