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S WRCB,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: ARP MINI MART 76 Date of Testing: 4/04/08 <br /> Facility Address: 25775 S.Patterson Road <br /> Facility Contact: Neilsh Patel Phone: (209)835-7777 <br /> Date Local Agency Was Notified of Testing: 3/24/08 <br /> Name of Local Agency Inspector(rf present during testing): Michelle Henry <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company RELIABLE PETROLEUM SERVICES INC. <br /> Technician Conducting Test: Guadalupe Sanchez <br /> Credentials': X CSLB Contractor X ICC Service Tech. ❑SWRCB Tank Tester ❑Other(Spec) <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 T3: 87 Blue Siphon T4:91 Gold Fill <br /> Number, Stored Product, etc), Fill <br /> Bucket Installation Type: Direct Bury Direct Bury Direct Bury Direct Bury <br /> X Contained in Sump X Contained in Sump Contained in Sump Contained in Sum <br /> Bucket Diameter: 12" 12" <br /> Bucket Depth: 13%" 14 1/2" <br /> Wait time between applying <br /> 2min. 2min. <br /> vacuum/water and start of test: <br /> Test Start Time(Tj): 9:22a.m 9:21a.m <br /> Initial Reading(Rj): 11 1/8" 11 " <br /> Test End Time(TF): 10:24a.m 10:24a.m <br /> Final Reading(RF): 11 1/8" 11" <br /> Test Duration(TF—Ti): 1 hr.2min. 1hr.3min. <br /> Change in Reading(RF-RI): 0 0 <br /> Pass/Fail Threshold or 1/16" 1/16" <br /> Criteria: <br /> Test Result: X Pass Fail X Pass Fail Pass Fail Pass Fail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> Drain Valve O-ring- and fill cap were replaced on T4: 91 Fill Spill Bucket w/drain <br /> Valve assv and fill can were replaced on 13. 87 Blue Siphon <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-_ Date: 04/04/08 <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 />