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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 thefacility owner/operatorfor submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: ARCO Date of Testing: 11/24/2010 <br /> Facility Address: 4855 S.State Route 9?Stockton,Ca.95215 <br /> Facility Contact: Gill I Phone: (209)481-7445 <br /> Date Local Agency Was Notified of Testing: I-1 tl-1 <br /> Name of Local Agency Inspector(ifpresent during testing): Aris Cacapit <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(Specify) <br /> License Number(s): 883706 5250451 <br /> 3. SPELL BUCKET TESTING INFORMATION <br /> Test Method Used: xHydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used: Standard Tape Measure Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1 Tl: 87 Fill 2 T2: 89 Fill 3 T3: 91 Fill 4 T4: <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 ❑Contained in Sum <br /> Bucket Diameter: 12" 12" 12" <br /> Bucket Depth: 13 '/4" 13 ''/2" 13 '/4" <br /> Wait time between applying 1 minute I minute 1 minute <br /> vacuum/water and start of test: <br /> Test Start Time(Tj): 2:50 p.m. 2:50 p.m. 2:50 p.m. <br /> Initial Reading(R,): 11 3/." 115/8" 12 1/8" <br /> Test End Time(TF): 3:50 p.m. 3:50 p.m. 3:50 p.m. <br /> Final Reading Qtr): 11 3/I' 115/81, 12 1/8" <br /> Test Duration(TF-Ti): 1 hr I hr 1 hr <br /> Change in Reading(RF-Rj): 0 0 0 <br /> Pass/Fail Threshold or 1/16" 1/16" 1/16" <br /> Criteria: <br /> Test Result: x Pass ❑Fail x Pass ❑Fail x Pass ❑Fail Pass ❑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 Signature: "" <br /> «-" -- Date 11/24/2010 <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 />