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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 71 Y 11'�h1121IN/ , Y tWi <br />Facility Name: 7 -ELEVEN #32262, MKT 2368 (N-3940-1 Date of Testing: 3/3/2016 <br />Facility Address: 2360 W GRANTLINE I-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. 3 <br />Technician Conducting Test: Nicolas Poblano <br />Credentialsl: r7 CSLB Contractor W ]CC Service Tech. SWRCB Tank Tester Other (Specify) a s <br />License Number(s): <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used By: Hydrostatic r—' vacuum 1_� Other <br />Test Equipment Used: VPLT Equipment Resolution: 0.00001 in. <br />tt x4 <br />Tv -f , <br />' r <br />k��tF <br />" r_�..— .�.' ,. „.». <br />,,�F �, d.:..a..-d rf ^,.o;,,�i sit, s3Yt_,, <br />.. ,. , z .zs`"�J <br />�. `� ft�-�.., s'—,�oonu�r-i' i iji F� <br />o,c aa.=1�tti� —yt ,¢ <br />Spill Box # Tank T4 RUL <br />Spill Box # Tank T5 MUL <br />Spill Box # Tank T6 PUL <br />Identify Spill Bucket (By Tank <br />REG I EAD -Fill I - <br />MIDGRADE -Fill 1 -Direct <br />PREMIUM - Fill 1 - Direct - <br />Spill Box # <br />Number, Stored Product, etc.) <br />Direct - Grade level in <br />- Grade level in <br />Grade level in containment <br />containment sump <br />containment sump <br />sump <br />f Direct Bury <br />f', Direct Bury <br />r Direct Bury <br />r Direct Bury <br />Bucket Installation Type: <br />I? Contained in Sump <br />0 Contained in Sump <br />G Contained in Sump <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 />5 min <br />5 min <br />5 min. <br />min <br />vacuum/water and start of test <br />Test Start Time (TF): <br />09:48:00 <br />12:00:00 <br />11:13:00 <br />Initial Reading (Rt): <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—Rt) : <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 />1,1 n.:: r <br />��r` <br />`moi r U 4 z T <br />�, i �;? <br />F y <br />all <br />ti�v�i <br />aF t <br />',tli <br />�i,�,�. � � ✓rfi <br />r��� � 4- <br />,-r Z moi? <br />„°'�����k�i%pi <br />��- <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 contained in this report is true, accurate, and in full compliance with legal requirements. <br />Technician's Signature: t� / Date: 3/3/2016 <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: 2325965 <br />