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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/operator for submittal to the local regulatory agency. <br /> 1 . FACILITY INFORMATION <br /> Facility Name: 7-ELEVEN 432190, MKT 2368 Date of Testing: 4/30/2019 <br /> Facility Address: 4943 S. KINGSLEY (FRONTAGE RD) I IWY 99 @ ARCH AIRPORT RD, STOCKTON, CA 95206 <br /> Facility Contact: MGR - LORENA Phone: 209-939-0679 <br /> Date Local Agency Was Notified of Testing : 4/23/2019 _ <br /> Name of Local Agency Inspector (if present during testing): UNKOWN <br /> 2 . TESTING CONTRACTOR INFORMATION <br /> L <br /> y Name: TANKNOLOGY INC. <br /> cian Conducting Test: Jesus Saldivar <br /> tials ' : CSLB Contractor W ICC Service Tech. r' SWRCB Tank Tester r Other (Specify)e Number(s) : <br /> 3 . SPILL BUCKET TESTING INFORMATION <br /> Test Method Used By : Hydrostatic Vacuum Other <br /> i <br /> Test Equipment Used: LAKE TEST Equipment Resolution : 0.0625 in. <br /> C <br /> F <br /> Identify Spill Bucket (By Tank Spill Box # Tank T4 RUL - Spill Box # Tank T5 MUL - Spill Box # Tank T6 PUL - <br /> Fill 1 - Direct - Grade level Fill 1 - Direct - Grade level Fill 1 - Direct - Grade level Spill Box <br /> Number, Stored Product, etc) # <br /> in containment sump in containment sump in containment sump <br /> I r Direct Bury r Direct Bury r Direct Bury r Direct Bury <br /> Bucket Installation Type : I: Contained in Sump + Contained in Sump 1* Contained in Sump r Contained in Sump <br /> Bucket Diameter: 12.00 12.00 12.00 <br /> Bucket Depth: 16.00 17.00 18.00 <br /> Wait time between applying 5 min 5 min 5 min min <br /> vacuum/water and start of test <br /> Test Start Time (TI): 08:00:00 08:00:00 08:00:00 <br /> Initial Reading (RI): 16.00 in. H2O 17.00 in. H2O 18.00 in. H2O <br /> Test End Time(TF): 09:00:00 09:00:00 09:00:00 <br /> Final Reading (RF): 16.00 in. H2O 17.00 in. H2O 18.00 in. H2O <br /> Test Duration(TF-TI): 1 hr 1 hr 1 hr <br /> Change in Reading (RF-RI) : 0.00 in. H2O 0.00 in. H2O 0.00 in. H2O <br /> Pass/Fail Threshold or Criteria: +/- 0.00 +/- 0.00 +/- 0.00 <br /> TestResult: Pass Pass Pass <br /> Comments - (include information on repairs made prior to testing, and r•ecomrtiended 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 true, accurate, and in full compliance with legal requirements. <br /> Technician's Signature : LAW 44� Date : 4/30/2019 <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: 2339855 <br />