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SWRCB, January 2006 <br /> Spill Bucket Testing Report Form <br /> This fora: 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 #32262, MKT 2368 (N-3940- 1 Date of Testing: 3/1 /2019 <br /> Facility Address : 2360 W GRANTLINE I-205 OFF RAMP, TRACY, CA 95376 <br /> Facility Contact: CHANDRA Phone: 209-830-9917 <br /> Date Local Agency Was Notified of Testing: 2/22/2019 <br /> Name of Local Agency Inspector (ifpresent during testing): Yuna <br /> 2 . TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY INC. <br /> Technician Conducting Test: Steve Willems <br /> _ <br /> Credentials ) : F CSLB Contractor W- ICC Service Tech. f` SWRCB Tank Tester F Other (Specify) <br /> License Number(s) : A <br /> 3 . SPILL BUCKET TESTING INFORMATION <br /> Test Method Used By : Hydrostatic Vacuum Other <br /> Test Equipment Used: LAKE TEST Equipment Resolution : 0.0625 in. <br /> Spill Box # Tank T4 RUL Spill Box # Tank T5 MUL Spill Box # Tank T6 PUL <br /> Identify Spill Bucket (By Tank REG UNLEAD - Fill 1 - MIDGRADE - Fill I - Direct PREMIUM - Fill I - Direct - Spill Box # <br /> Number, Stored Product, etc) Direct - Grade level in - Grade level in Grade level in containment <br /> containment sump containment sump sump <br /> r Direct Bury C Direct Bury f Direct Bury r Direct Bury <br /> Bucket Installation Type : (; Contained in Sump f• Contained in Sump G Contained in Sump r Contained in Sump <br /> Bucket Diameter: 12.00 12.00 12.00 <br /> Bucket Depth : 13.75 13 .50 12.00 <br /> Wait time between applying <br /> 5 min 5 min 5 min min <br /> vacuum/water and start of test <br /> Test Start Time (Tl): 10:52:00 10:52:00 10:52:00 <br /> Initial Reading (Rl): 12.50 in. H2O 12.50 in. H2O 11 .00 in. H2O <br /> Test End Time(TF): 11 :52:00 11 :52:00 11 :52:00 <br /> Final Reading (RF): 12.50 in. H2O 12. 50 in. H2O 11 .00 in. H2O <br /> Test Duration(TF—Tl): 1 hr 1 hr 1 hr <br /> Change in Reading (RF—Rl) : 0.00 in. H2O 0.00 in. H2O 0.00 in. H2O <br /> i <br /> Pass/Fail Threshold or Criteria: +/- 0.00 +/- 0.00 +/- 0.00 <br /> Test Result: Pass Pass Pass <br /> I <br /> Comments - (include information on repairs made prior to testing, and reconnnended follow-up for failed tests) <br /> i <br /> CERTIFICATION OF TECFINICIAN 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 : Q� Date : 3/ 1 /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 : 2339857 <br />