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SWRCB, January 2006 <br /> Spill Bucket Testing Report Form <br /> This forst is intended for use by contractors petforming 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 35355 Date of Testing: 2/6/2020 <br /> Facility Address : 3202 W HAMMER LANE (N436) , STOCKTON, CA 95209 <br /> Facility Contact: MANAGER Phone 209-951 -3345 <br /> Date Local Agency Was Notified of Testing : 1 /30/2020 _ <br /> Name of Local Agency Inspector (if present during testing): UNKNOWN <br /> 2 . TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY INC. - U. ^( TO _ <br /> Technician Conducting Test: Jesus Saldivar _- k <br /> _ ( P fJ ) a apt <br /> Credentialsi : F CSLB Contractor V ICC Service Tech r- SWRCB Tank Tester F Other S eci � E t F � y � (fib ` � � • <br /> ; FZ <br /> License Number(s) : ) V 1 % <br /> 3 . SPILL BUCKET TESTING INFORMATION <br /> Test Method Used By : Hydrostatic Vacuum Other <br /> Test Equipment Used : LAKE TEST Equipment Resolution : 0.0625 in. <br /> Identify Spill Bucket (By Tank Spill Box # Tank Tl : RUL - Spill Box # Tank T2: PUL ,,, Spill Box # Tank T3 : Diesel <br /> Fill I - Direct - Grade level Fill 1 - Direct - Grade level - Fill 1 - Direct ,,,e Grade level Spill Box # <br /> Number, Stored Product, etc.) in containment sump in containment sump in containment sump <br /> r Direct Bury r Direct Bury (` Direct Bury (" Direct Bury <br /> Bucket Installation Type : (; Contained in Sump (• Contained in Sump ro Contained in Sump r Contained in Sump <br /> Bucket Diameter: 12.00 12.00 12.00 <br /> Bucket Depth : 15.00 15.00 15.00 <br /> Wait time between applying 5 min 5 min 5 min min <br /> vacuum/water and start of test <br /> Test Start Time (Tl): 08 :00:00 08:00:00 08:00:00 <br /> Initial Reading (Rt): 15.00 in. H2O 15.00 in. H2O 15.00 in. H2O <br /> Test End Time(TF): 09:00:00 09:00:00 09:00:00 <br /> ( F)� <br /> Final Reading (RF) 15 .00 in. H2O 15.00 in. H2O 15.00 in. H2O <br /> Test Duration(TF--TI): 1 hr 1 hr 1 lir <br /> Change in Reading (Rg—RI) : 0.00 in. H2O 0.00 in. H2O 0.00 in. H2O <br /> Pass/Fail Threshold or Criteria: +/- 0000 +/- 0. 00 +/- 0.00 <br /> Test Result: Pass Pass Pass <br /> Comments - (include information on repairs made prior to testing, and recwnmended follow-up 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 : /�wZ64. Date : 2/6/2020 <br /> 1 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 : 2344049 <br />