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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 fi•orn 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: 2/6/2019 <br />Facility Address: 3202 W HAMMER LANE (N436), STOCKTON, CA 9520-9 <br />Facility Contact: MANAGER Phone: 209-951-3345 <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: Michael Deatherage <br />Credentialsi : CSLB Contractor W' ICC Service Tech. SWRCB Tank Tester r' Other <br />License Number(s): 8819901 <br />3. SPILL BUCKET TESTING INFORMATION <br />Comments - (include information on repairs made prior to testing, and recommended 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 hue, accurate, and in full contpliartce wish Zegal requirements. <br />G .! <br />Technician's Signature: / 0 <br />' <br />Date: 2/6/2019 <br />rState laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more stringent. <br />WO: 2339403 <br />Test Method Used By: Hydrostatic Vacuum Other <br />Test Equipment Used: LAKE TEST <br />Equipment Resolution: 0.0625 in. <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />Spill Box # Tank Tl: RUL- <br />Fill 1 - Direct - Grade level <br />in containment sump <br />Spill Box # Tank T2: PUL - <br />Fill 1 - Direct- Grade level <br />in containment sump <br />Spill Box # Tank T3: Diesel <br />"Fill I - Direct- Grade level <br />in containment sump <br />Spill Box # <br />Bucket Installation Type: <br />(" Direct Bury <br />Contained in Sump <br />i^ Direct Bury <br />r Contained in Sump <br />r Direct Bury <br />t+ Contained in Sump <br />f Direct Bury <br />t Contained in Sump <br />Bucket Diameter: <br />11.00 <br />11.00 <br />11.00 <br />Bucket Depth: <br />15.00 <br />15.50 <br />15.25 <br />Wait time between applying <br />vacuum/water and start of test <br />IS min <br />15 min <br />IS min <br />min <br />Test Start Time (Tl): <br />11:00:00 <br />11:00:00 <br />11:00:00 <br />Initial Reading (RI): <br />15.00 in. <br />15.50 in. <br />15.25 in. <br />Test End Time(TF): <br />12:00:00 <br />12:00:00 <br />12:00:00 <br />Final Reading (RF): <br />15.00 in. <br />15.50 in. <br />15.25 in. <br />Test Duration(TF—TI): <br />1 hr <br />1 hr <br />I hr <br />Change in Reading (RF—RI) : <br />0.00 in. <br />0.00 in. <br />0.00 in. <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 TECIINICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />I hereby certify that all the information contained in this report is hue, accurate, and in full contpliartce wish Zegal requirements. <br />G .! <br />Technician's Signature: / 0 <br />' <br />Date: 2/6/2019 <br />rState laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more stringent. <br />WO: 2339403 <br />