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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. FACILITY INFORMATION <br />Facility Name: 7 -ELEVEN #32262, MKT 2368 (N-3940-1 Date of Testing: 3/3/2017 <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 13 1017 <br />Company Name: TANKNOLOGY INC. <br />Technician Conducting Test: Jesus Saldivar ENVIRONMENTAL HEALTH <br />Credentials): r— CSLB Contractor ICC Service Tech. SWRCB Tank Tester r— Other (Specify) DERART M T <br />License Number(s): <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used By: P7 Hydrostatic Vacuum Other <br />Test 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 />REG UNLEAD - Fill 1 - <br />Direct - Grade level in <br />containment sump <br />Spill Box # Tank T5 MUL <br />MIDGRADE - Fill 1 - Direct <br />- Grade level in <br />containment sump <br />Spill Box # Tank T6 PUL <br />PREMIUM - Fill 1 - Direct - <br />Grade level in containment <br />sump <br />Spill Box # <br />Bucket Installation Type: <br />C' Direct Bury <br />i+ Contained in Sump <br />Direct Bury <br />r Contained in Sump <br />r Direct Bury <br />fo Contained in Sump <br />f Direct Bury <br />r Contained in Sump <br />Bucket Diameter: <br />14.00 <br />14.00 <br />14.00 <br />Bucket Depth: <br />13.00 <br />13.00 <br />13.00 <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 />10:13:00 <br />10:13:00 <br />10:13:00 <br />Initial Reading (Rl): <br />13.50 in. H2O <br />13.50 in. H2O <br />13.50 in. H2O <br />Test End Time(TF): <br />11:13:00 <br />11:13:00 <br />11:13:00 <br />Final Reading (RF): <br />13.50 in. H2O <br />13.50 in. H2O <br />13.50 in. H2O <br />Test Duration(TF—TI): <br />1 hr <br />1 hr <br />1 hr <br />Change in Reading (RF—RI) : <br />0.00 in. H2O <br />0.00 in. 1420 <br />0.00 in. H2O <br />Pass/Fail Threshold or Criteria: <br />+/-0.00 <br />+/-0.00 <br />+/-0.00 <br />+/- <br />Test Result: <br />Pass <br />Pass <br />Pass <br />Comments - (include information on repairs made prior to testing, 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: Date: 3/3/2017 <br />1State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more stringent. <br />WO: 2330236 <br />