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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#20632,MKT 2368 Date of Testing: 12/13/2023 <br /> Facility Address:4627 DA VINCI DR @ MARCH LN,STOCKTON,CA 95207 <br /> Facility Contact:MGR-SATBIR(P'rO#N-748) Phone:209-952-3543 <br /> Date Local Agency Was Notified of Testing: 12/13/2023 <br /> Name of Local Agency Inspector(if present during testing):UNKNOWN <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Nwne:TANKNOLOGY INC. <br /> Technician Conducting Test:Jesus Saldivar <br /> Credentials I: r CSLB Contractor FF ICC Service Tech. r7 SWRCB Tank Tester r7' Other(Specify) <br /> License Number(s): <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used By: r Hydrostatic P— Vacuum r Other <br /> lest Equipment lJsed: VACUUMTEST Equipment Resolution:0.1 -ph <br /> Spill Box#Tank 3 Spill Box#Tank 4 Spill Box#Tank 5 Diesel- <br /> Identify Spill Bucket(By Tank REGULAR-Fill l-Direct- PREMIUM-Fill 1 -Direct- Fill 1-Direct-Grade level Spill Box# <br /> Number,Stored Product, etc.) Grade level in containment Grade level in containment in containment sump <br /> sump sump <br /> C' Direct Bury f Direct Bury f Direct Bury f Direct Bury <br /> Bucket Installation Type: (? Contained in Sump Co Contained in Sump fo Contained in Sump f Contained in Sump <br /> Bucket Diameter: 12.00 12.00 12.00 <br /> Bucket Depth: 15.00 15.00 15.00 <br /> Wait time between applying <br /> 1 min 1 min 1 min min <br /> vacuum/water and start of test <br /> Test Start Time(Tl): 09:00:00 09:02:00 09:04:00 <br /> Initial Reading(RI): 30.00 in.H2O 30.00 in.H2O 30.00 in.H2O <br /> Test End Time(TO 09:01:00 09:03:00 09:05:00 <br /> Final Reading(RF): 30.00 in.H2O 30.00 in.H2O 30.00 in.H2O <br /> Test Duration(TF—TI): I min 1 min 1 min <br /> Change in Reading(RF—RI): 0.00 in.H2O 0.00 in.H2O 0.00 in.H2O <br /> Pass/Fail Threshold or Criteria: +/-4.00 +/-4.00 +1-4.00 <br /> Test Result: Pass Pass Pass <br /> Comments-(include it formntior)on rehuir c mule!)riot.to testing, and reconzntended follma,-ttlr for foiled tewv) <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: /—die—' Date: 12/13/2023 <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:2363183 <br />