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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%perator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: 7 -Eleven 38153 Date of Testing: 4/19/2019 <br />Facility Address: 121 S. Center Street, Stockton, CA 95202 <br />Facility Contact: Phone: - <br />Date Local Agency Was Notified of Testing: 4/12/2019 <br />Name of Local Agency Inspector (ifpresent during testing): ZUNA <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: TANKNOLOGY INC. <br />Technician Conducting Test: Jesus Saldivar <br />Credentials): r CSLB Contractor r ICC Service Tech. SWRCB Tank Tester r- Other (Specify) <br />License Number(s): <br />3. SPILL BUCKET TESTING INFORMATION <br />Comments - (include information on repairs made prior to testing, and recommended follow-up for <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 T 1: <br />REGULARUNLEADED <br />REG UNLEAD - Fill 1- <br />Direct - Grade level <br />Spill Box # Tank T2: <br />PREMIUM UNLEADED <br />PREMIUM - Fill I - Direct - <br />Grade level <br />Spill Box #Tank T3:DIESEL <br />Diesel - Fill 1 - Direct - <br />Grade level <br />Spill Bos # <br />Bucket Installation Type: <br />r Direct Bury <br />(: Contained in Sump <br />r Direct Bury <br />G Contained in Sump <br />r Direct Bury <br />{+ Contained in Sump <br />r Direct Bury <br />r Contained in Sump <br />Bucket Diameter: <br />12.00 <br />12.00 <br />12.00 <br />Bucket Depth: <br />16.00 <br />16.00 <br />17.00 <br />Wait time between applying <br />vacuum/water and start of test <br />5 rein <br />5 min <br />5 min <br />min <br />Test Start Time (Tt): <br />09:00:00 <br />09:00:00 <br />09:00:00 <br />Initial Reading (RI): <br />16.00 in. H2O <br />16.00 in. H2O <br />17.00 in. H2O <br />Test End Time(TF): <br />10:00:00 <br />10:00:00 <br />10:00:00 <br />Final Reading (RF): <br />16.00 in. H2O <br />16.00 in. H2O <br />17.00 in. H2O <br />Test Duration(TF—Tj): <br />I hr <br />I hr <br />1 hr <br />Change in Reading (RF—RI): <br />0.00 in. H2O <br />0.00 in. H2O <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 />failed tests) <br />CERTIFICATION OF TECi�NICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />I Iaereby certify that all the information contained in this report is true, accurate, aced in full coneplimece wide legal requirements. <br />Technician's Signature: 144WZ&/� <br />Date: 4/19/2019 <br />r 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: 2341372 <br />