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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 contaitvttent structures. The completed form and <br /> printouts front tests (f 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 41187 Date of Testing : 9/7/2021 <br /> Facility Address . 1829 N Wilson Way , Stockton, CA 95204 <br /> Facility Contact: Phone: 209-414-7328 <br /> Date Local Agency Was Notified of Testing : 9/7/2021 <br /> Name of Local Agency Inspector (rf present during testing): Environmental <br /> 2 . TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY INC. <br /> Technician Conducting Test: Brent Bowen <br /> Credentials ' : CSLB Contractor W ICC Service Tech. SWRCB Tank Tester Other (Specify) <br /> License Number(s) : 74360 <br /> 3 . SPILL BUCKET TESTING INFORMATION <br /> Test Method Used By : Hydrostatic 17, Vacuum Other <br /> Test Equipment Used : LAKE TEST Equipment Resolution: 0.0625 in. <br /> Identify Spill Bucket (By Tank Spill Box # Tank T1 Spill Box # Tank T2 Spill Box # Tank T3 dsl <br /> Number, Stored Product, etc.) REGULAR - Fill 1 - Direct - PREMIUM - Fill I - Direct - Diesel - Fill 1 - Direct - Spill Box # <br /> Grade level Grade level Grade level <br /> Direct Bury (- Direct Bury r Direct Bury r Direct Bury <br /> Bucket Installation Type: t; Contained in Sump Contained in Sump (+ Contained in Sump f Contained in Sump <br /> Bucket Diameter: 12.00 12.00 12.00 <br /> Bucket Depth: 16.00 16.00 16.00 <br /> Wait time between applying 15 min 15 min 15 min min <br /> vacuum/water and start of test <br /> Test Start Time (Tl): 11 :00:00 11 :00:00 11 :00:00 <br /> Initial Reading (RI): 14.00 in . 14.00 in . 14.00 in . <br /> Test End Time(TF): 12:00:00 12:00:00 12:00:00 <br /> Final Reading (RF): 14.00 in. 14.00 in. 14.00 in. <br /> Test Duration(TF—Tl ): 1 hr 1 hr 1 hr <br /> Change in Reading (RF—Rl) : 0.00 in. 0.00 in. 0.00 in. <br /> Pass/Fail Threshold or Criteria: +/- 0 .00 +/- 0.00 +/- 0.00 +/- <br /> Test Result: Pass Pass Pass <br /> Comments - (include information on repairs made prior to testing, and reconartrended follow-up for failed tests) <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 : 9/7/2021 <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 : 2353207 <br />