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SVyRCB, January 2006 <br />Spill Bucket Testing Report Forma, <br />This form is intended for use by contractors performing annual testing of UST spill containment structures. The completed formgq9� <br />printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory ages l j <br />1. FACILITY INFORMATION <br />Facility Name: 7 -ELEVEN #32262, MKT 2368 (N-3940-1 Date of Testing: 3/3/2016 <br />Facility Address: 2360 W GRANTLINE 1-205 OFF RAMP, TRACY, CA 95376 <br />Facility Contact: CHANDRA Phone: 209-830-9917 <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (if present during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: TANKNOLOGY INC. <br />Technician Conducting Test: Nicolas Poblano <br />Credentials): r7 CSLB Contractor r7i ICC Service Tech. � SWRCB Tank Tester r7, Other (Specify) <br />License Number(s): <br />3- SPILL BUCKET TESTING INFORMATION <br />Test Method Used By: Hydrostatic r— Vacuum Other <br />Test Equipment Used: VPLT Equipment Resolution. 0.00001 in. <br />WAN ,1 G . J <br />0 a 01 <br />Spill Box # Tank T4 RUL Spill Box # Tank T5 MUL Spill Box # Tank T6 PUL <br />Identify Spill Bucket (By Tank REG UNLEAD - Fill I - MIDGRADE - Fill 1 - Direct PREMIUM - Fill 1 - Direct - Spill Box # <br />Number, Stored Product, etc.) Direct - Grade level in - Grade level in Grade level in containment <br />containment sump containment sump sump <br />Bucket Installation Type: <br />Direct Bury <br />0 Contained in Sump <br />r Direct Bury <br />if Contained in Sump <br />r Direct Bury <br />f+ Contained in Sump <br />r Direct Bury <br />r Contained in Sump <br />Bucket Diameter: <br />10.50 <br />10.50 <br />10.50 <br />Bucket Depth: <br />16.00 <br />16.00 <br />13.25 <br />Wait time between applying <br />vacuum/water and start of test <br />5 min <br />5 min <br />5 min <br />min <br />Test Start Time (Tl): <br />09:48:00 <br />12:00:00 <br />11:13:00 <br />Initial Reading (Rj): <br />14.50 in. <br />14.50 in. <br />12.25 in. <br />Test End Time(TF): <br />09:48:00 <br />12:10:00 <br />12:13:00 <br />Final Reading (RF): <br />14.50 in. <br />13.00 in. <br />12.25 in. <br />Test Duration(TF—TI): <br />I hr <br />10 min <br />1 hr <br />Change in Reading (RF—RI): <br />0.00 in. <br />-1.50 in. <br />0.00 in. <br />Pass/Fail Threshold or Criteria: <br />+/-0.00 <br />+/-0.00 <br />+/-0.00 <br />+/- <br />,. <br />�� <br />�a 91 g r=��: <br />�,�f <br />Comments - (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />Spill bucked 89 grade failed after inspection of bucket found that jack screw assembly was damaged. needs to be repaired and retested. <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />I hereby certify that all the information container[ in this report is true, accurate, and in full compliance with legal requirements. <br />Technician's Signature: *-K Date: 3/3/2016 <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: 2325965 <br />