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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 forst and <br /> printouts fidom tests (if applicable) , should be provided to the facility oumer/operator for submittal to the local regulator}) agency. <br /> 1 . FACILITY INFORMATION <br /> Facility Name: 7-ELEVEN 14113 , MKT 2368 Date of Testing : 9/ 11 /2019 <br /> Facility Address : 3040 BENJAMIN HOLT DR a GRIGSBY , STOCKTON, CA 95219 <br /> Facility Contact: STORE MANAGER Phone : 209-478-3040 <br /> 11 r Ir r <br /> Date Local Agency Was Notified of Testing: 8/28/2019 <br /> Name of Local Agency Inspector (if present during testing): STACY RIVERA <br /> 2 . TESTING CONTRACTOR INFORMATION <br /> Company Name : TANKNOLOGY INC. <br /> Technician Conducting Test: Jesus Saldivar <br /> Credentials ( : CSLB Contractor F ICC Service Tech. r� SWRCB Tank Tester Other (Specify) <br /> License Number(s) : <br /> 3 . SPILL BUCKET TESTING INFORMATION <br /> Test Method Used By : We' Hydrostatic Vacuum F, Other <br /> Test Equipment Used : LAKE TEST Equipment Resolution : 0.0625 in. <br /> Spill Box # Tank T 1 Spill Box # Tank T2 <br /> Identify Spill Bucket (By Tank REGULAR - Fill I - Direct - SUPREME . Fill 1 - Direct - Spill Box # Spill Box # <br /> Number, Stored Product, etc.) Grade level in containment Grade level in containment <br /> sump sump <br /> (' Direct Bury r Direct Bury r Direct Bury r Direct Bury <br /> Bucket Installation Type : (o Contained in Sump re Contained in Sump r Contained in Sump f Contained in Sump <br /> Bucket Diameter: 12.00 12.00 <br /> Bucket Depth : 13 .00 13 .00 <br /> Wait time between applying <br /> vacuum/water and start of test 5 ruin 5 rnin min min <br /> Test Start Time (Tl ): 09:00:00 09:00:00 <br /> Initial Reading (RI ): 13 .00 in. H2O 13 .00 in. H2O <br /> Test End Titne(TF): 10:00:00 10:00:00 <br /> Final Reading (RF): 13 .00 in. H2O 13 .00 in. H2O <br /> Test Duration(TF-TI ): 1 hr I hr <br /> Change in Reading (RF-RI ) : 0.00 in. H2O 0.00 in. H2O <br /> Pass/Fail Threshold or Criteria : - +/- 0.00 +/- 0.00 +/- +/- <br /> Test Result: Pass Pass <br /> Comments - (include information on repairs made prior to testing, and recar)imerrcled follow- up for t� <br /> RE L; E V E <br /> SEP!6 2019 <br /> ENVIRONMENTAL HEALTH <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTINGS R V I C E S <br /> I hereby certify that all the information contained in this report is hue, accurate, and in fall compliance with legal requirements. <br /> Technician's Signature : Date : 9/ 11 /2019 <br /> i <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 : 2342147 <br /> I <br />