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SWRCB, January 2006 <br /> Spill Bucket Testing Report Form <br /> This fora: is intended for use by contractors per forming 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 417334 MKT 2368 (N-747) Date of Testing: 9/23/2020 <br /> Facility Address: 4501 N. PERSHING AVE. @ ROSEMARIE LN., STOCKTON, CA 95207 <br /> Facility Contact: MGR - SATBIR Phone : 209-951 -6745 <br /> Date Local Agency Was Notified of Testing: 9/23/2020 <br /> Name of Local Agency Inspector (ifpresent during testing): Vicky Vang-Lee <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. r SWRCB Tank Tester r Other (Specify) <br /> License Number(s) : <br /> 3 . SPILL BUCKET TESTING INFORMATION <br /> Test Method Used By : Hydrostatic IA Vacuum Other <br /> Test Equipment Used: LAKE TEST Equipment Resolution : 0.0625 in. <br /> Identify Spill Bucket (By Tank Spill Box # Tank T- 1 RUL . Spill Box # Tank T-2 PUL - Spill Box # Spill Box # <br /> Number, Stored Product, etc.) Fill 1 - Direct - Grade level Fill 1 - Direct - Grade level <br /> f• Direct Bury (+ Direct Bury r Direct Bury t- Direct Bury <br /> Bucket Installation Type: r Contained in Sump r Contained in Sump f Contained in Sump r Contained in Sump <br /> Bucket Diameter: 12.00 12.00 <br /> Bucket Depth : 16.00 14.00 <br /> Wait time between applying 5 min 1 min min min <br /> vacuum/water and start of test <br /> Test Start Time (TI): 12: 13 :00 10:00:00 <br /> Initial Reading (RI): 16.00 in. H2O 30.00 in. H2O <br /> Test End Time(TF): 13 : 13 :00 10:01 :00 <br /> Final Reading (RF): 16.00 in. H2O 30.00 in. H2O <br /> Test Duration(TF-TI): 1 hr 1 min <br /> Change in Reading (RF-RI) : 0.00 in. H2O 0.00 in. H2O <br /> Pass/Fail Threshold or Criteria: +/- 0.00 +/- 4.00 +/- +/- <br /> F Test Result: Pass Pass <br /> Comments - (include information on repairs made prior to testing, and reconuriended follow-up for failed tests) <br /> tested reg with H2O due to not getting a good suction. and Prem. was tested with vacuum unit, <br /> and passed <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 : 9/23/2020 <br /> I 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 : 2346947 <br /> t <br /> i' <br />