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SWRCB, January 2006 <br /> Spill Bucket Testing Report Form <br /> This fornz is intended for use by contractors pezforming annual testing of UST spill containment structures. The completed fornz and <br /> printouts from tests (if applicable), should be provided to the facility owner/operato• for submittal to the local regulatory agency. <br /> 1 . FACILITY INFORMATION <br /> Facility Nance: 7-ELEVEN #32190, MKT 2368 Date of Testing: 4/22/2020 <br /> Facility Address: 4943 S. KINGSLEY (FRONTAGE RD) I-WY 99 @ ARCH AIRPORT RD, STOCKTON, CA 95206 <br /> Facility Contact: MGR - LORENA Phone: 209-939-0679 <br /> Date Local Agency Was Notified of Testing : 4/ 16/2020 <br /> Name of Local Agency Inspector (ifpresent during testing): Shewit <br /> 2 . TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY INC. <br /> Technician Conducting Test: Clint Fuhrman <br /> Credentialsl : CSLB Contractor r ICC Service Tech. r, SWRCB Tank Tester FA Other (Specify) <br /> License Number(s) : 9160945 <br /> 3 . SPILL BUCKET TESTING INFORMATION <br /> Test Method Used By : W Hydrostatic Vacuum Other <br /> Test Equipment Used: LAKE TEST Equipment Resolution : 0.0625 in. <br /> Identify Spill Bucket (By Tank Spill Box # Tank T4 RUL - Spill Box # Tank T5 MUL - Spill Box # Tank T6 PUL - <br /> Number, Stored Product, etc.) Fill 1 - Direct - Grade level Fill 1 - Direct - Grade level Fill 1 - Direct - Grade level Spill Box # <br /> in containment sump in containment sump in containment sump <br /> (` Direct Bury (` Direct Bury r Direct Bury (` Direct Bury <br /> Bucket Installation Type : (: Contained in Sump !+ Contained in Sump (+ Contained in Sump f Contained in Sump <br /> Bucket Diameter: 12.00 12.00 12.00 <br /> Bucket Depth : 16.00 16.00 16.00 <br /> Wait time between applying <br /> 5 min 5 min 5 min min <br /> vacuum/water and start of test <br /> Test Start Time (Tl ): 09:25:00 09:30:00 09:35:00 <br /> Initial Reading (RI): 14. 50 in. 14.50 in. 14.50 in. <br /> Test End Time(TF): 10:25 :00 10:30:00 10:35:00 <br /> Final Reading (RF): 14. 50 in. 14.50 in. 14.50 in. <br /> Test Duration(TF—TI ): 1 hr 1 hr 1 hr <br /> Change in Reading (RF—Rj) : 0.00 in. 0.00 in. 0.00 in. <br /> Pass/Fail Threshold or Criteria: +/- 0.00 +/- 0. 00 +/- 0.00 +/- <br /> Test Result: Pass Pass Pass <br /> COmmentS - (include information on repairs made prior to testing, and reconnzended follow- up for failed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the infor•rnation contained in this report is true, accurate, and in full compliance with legal requirements. <br /> Technician's Signature : ��JWio� Date : 4/22/2020 <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 : 2344612 <br />