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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 /> prtntouts from 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: ARCH ROAD ARCO AM PM Date of Testing: 12-31-09 <br /> Facility Address: 4855 State Route 99,Stockton CA 95215 <br /> Facility Contact: Gill Phone: 209-948-2438 <br /> Date Local Agency Was Notified of Testing: 12-07-09 <br /> Name of Local Agency Inspector(tf present during testing): Ray Von Flue <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. ❑SWRCB Tank Tester ❑Other(Spew) <br /> License Number(s): 883706 5250451-UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: X Hydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used: Standard Tape Measure Equipment Resolution:-- <br /> Identify Spill Bucket(By Tank T2: Mid Grade Fill Tl: 20k Regular Tl: 20k Regular T3: Premium Fill <br /> Number,Stored Product, etc.) North Fill South Fill <br /> Bucket Installation Type: 0 Direct Bury ❑Direct Bury ❑Direct Bury 0 Direct Bury <br /> X Contained in Sum X Contained in Sump X Contained in Sump X Contained in Sum <br /> Bucket Diameter: 12" 12" 12" 12" <br /> Bucket Depth: 12'h" 12'/2" 12" 12'/4" <br /> Wait time between applying <br /> vacuum/water and start of test: imin. imin. imin. ]min. <br /> Test Start Time(T�: 9:50a.m 9:51a.m 9:51a.m 9:55a.01 <br /> Initial Reading(R): 10%" 10'/d' 10 7/8" 11" <br /> Test End Time(TF): 10:50a.m 10:51a.m 10:51a.m 10:55a.m <br /> Final Reading(RF): 10'/." 10%" 107/811 11" <br /> Test Duration(TF—TO: 1 hr. 1hr. lhr. lhr. <br /> Change in Reading(RF-Rj): 0 0 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: 1/16" 1/16" 1/16" 1/16" <br /> Test Result: X Pass ❑Fail X Pass ❑Fail I X Pass ❑Fail X Pass ❑Fail <br /> Comments— (include information on repairs made prior to testing, and recommended ollow-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 Si --z.� �4�C!a. _--41�/ Date: 12-31-09 <br /> State laws and regulations de not currently require testing to be performed by a qualified contractor.However,local requirements <br /> may be more stringent. <br />