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0 • RE CFAVFjwQ2006 <br /> Spill Bucket Testing Report Form - z 3 2013 <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(f applicable), should be provided to the facility owner/operator for submitt f-N1#fW MK44T envy. <br /> 1. FACILITY INFORMATION HEALTH DEPARTMENT <br /> Facility Name: ARCO Date of Testing: 11/19/2013 <br /> Facility Address: 4855 S.State Route 9,Stockton,Ca.95215 <br /> Facility Contact: Gill Phone: (209)481-7445 <br /> Date Local Agency Was Notified of Testing: 1 b— — <br /> Name of Local Agency Inspector(f present during testing): Stacy Rivera <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Reliable Petroleum Services Inc. <br /> Technician Conducting Test: Guadalupe Sanchez <br /> Credentials: x CSLB Contractor x ICC Service Tech. 0 SWRCB Tank Tester 0 Other(Specify) <br /> License Number(s): 883706 5250451 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: xHydrostatic 11 Vacuum 0 Other <br /> Test Equipment Used: Standard Tape Measure Equipment Resolution: N/A <br /> Identify Spill Bucket(By Tank I TI: 87 Fill SE 2 Tl: 87 Fill NE 3 T2: 89 Fill 4 T3: 91 Fill <br /> Number, Stored Product, etc. <br /> Bucket Installation Type: Direct Bury Direct Bury Direct Bury Direct Bury <br /> x Contained in Sump x Contained in Sump x Contained in Sump x Contained in Sum <br /> Bucket Diameter: 12" 12" 12" 12" <br /> Bucket Depth: 13 ''/4" 13 3/4" 133/4" 13 3/d' <br /> Wait time between applying 1 minute 1 minute 1 minute 1 minute <br /> vacuum/water and start of test: <br /> Test Start Time(T[): 12:42 p.m. 12:42 p.m. 12:42 p.m. 12:42 p.m. <br /> Initial Reading(Rj): 11 1/8" 115/8" 12" 11 3/4" <br /> Test End Time(TF): 1:42 p.m. 1:42 p.m. 1:42 p.m. 1:42 p.m. <br /> Final Reading(RF): 11 1/8" 115/8" 12" 11 3/4" <br /> Test Duration(TF—Tj): I hr lhr 1 hr 1 hr <br /> Change in Reading(RF-Rj): 0 0 0 0 <br /> Pass/Fail Threshold or 1/16" 1/16" 1/16" 1/16" <br /> Criteria: <br /> Test Result: x Pass 0 Fail x Pass 0 Fail x Pass 0 Fail I x Pass 0 Fail <br /> Comments—(include information on repairs made prior to testing and recommended 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 Signa®ee� Date 11/19/2013 <br /> 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 />