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SWRCB, January 2006 <br />Spill Bucket Testing Report Form <br />This fornr 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 38153 <br />L Date of Testing: 4/19/2019 <br />Facility Address: 121 S. Center Street, Stockton, CA 95202 <br />Facility Contact: Phone: - <br />In - <br />Date Local Agency Was Notified of Testing: 4/12/2019 <br />Name of Local Agency Inspector (if present during testing): ZUNA <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: TANKNOLOGY INC. <br />Technician Conducting Test: Jesus Saldivar <br />Credentialsi : CSLB Contractor ICC Service Tech. <br />License Num <br />SWRCB Tank Tester � Other <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used By: �' Hydrostatic r' <br />Comments - (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />CERTIFICATION OF TECHMCIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />I hereby certify thaf all the fr:fm•nuuion contained in this report is true, accz[raie, and in full compliance with legal require»:eats. <br />Technician's Signature: /� 4L <br />Date: 4/19/2019 <br />t 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 />Vacuwn � 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 T1: <br />REGULARUNLEADED <br />REG UNLEAD - Fill I - <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 Box # <br />Bucket Installation Type: <br />(` Direct Bury <br />(; Contained in Sump <br />r Direct Bury <br />(+ Contained in Sump <br />(` Direct Bury <br />(: Contained in Sump <br />f 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 min <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 (Rt): <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—Tt): <br />1 hr <br />1 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 />Comments - (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />CERTIFICATION OF TECHMCIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />I hereby certify thaf all the fr:fm•nuuion contained in this report is true, accz[raie, and in full compliance with legal require»:eats. <br />Technician's Signature: /� 4L <br />Date: 4/19/2019 <br />t 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 />