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6EMER-RYAN INC. GR Job# 20-643301 <br /> f <br /> 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: Arco SS 2076 Date of Testing: 12/1.5/2016 <br /> Facility Address: 800 E. Kettleman Lane.Lodi,CA <br /> Facility Contact: Daryl Lee Phone: 415-902-5089 <br /> Date Local Agency Was Notified of Testing: <br /> Name of LocalAgency Inspector i present during testing): <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: Gettler-Ryan Inc.,6805 Sierra Court Suite G,Dublin,Ca.94568 Ph.#925-5.51-7555 <br /> Technician Conducting Test: David Rouse <br /> Credentials:(1) CSLB Contractor ICC service Tech. SWRCB Tank Tester Other(Specify) <br /> License Number: 220793 ICC Tech Number: 8292530-LIT <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: Hvdrostatic Vacuum Other <br /> Test Equipment Used: Standard Tape Measurer Equipment Resolution: I/16" <br /> Identify Spill Bucket(By Tank1 87-1 2 87-2 3 �-87-3 91 <br /> Number,.Stored Product,etc.)---7 Vapor 1•'a or I Vapor L Vapor <br /> Bucket Installation Type: <br /> Direct Bury Direct Bury Direct Bury Direct Bury <br /> x Contained in Sump x Contained in Sump x Contained in Sump x Contained in Sump <br /> Bucket Diameter: 12" 12" 12" 12" <br /> Bucket Depth: 14" 14" 14" 14" <br /> Wait time between applying <br /> Sorin Sorin Sorin Sorin <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 9:00 9:00 9:00 9:00 <br /> Initial Reading(Ri): 13" 13" 13" 13" <br /> Test End Time(Tf): 10:00 10:00 10:00 10:00 <br /> Final Reading(Rf) 13" 13" 13" 13" <br /> Test duration(Tf-Ti): 1 h r 1 h r I h r I h r <br /> Change in Reading(Rf-Ri): 0 0 0 0 <br /> Pass/Fail Threshold or Criteria: 0 0 0 0 <br /> Test Results: x Pass Fail x Pass Fail x Pass Fail x Pass Fail <br /> Comments-(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> CERTFICATION 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: x � �s/""~ /— -----__ Date: 12/15/2016 <br /> (1) State laws and regulations do not currently require testing to be performed by a qualified contractor. However. local requirements <br /> may be more stringent. <br />