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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 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: 03-27-09 <br /> Facility Address: 25775 S.Patterson Pass Road <br /> Facility Contact: Neilsh Patel Phone: (209)835-7777 <br /> Date Local Agency Was Notified of Testing: 03-24-09 <br /> Name of Local Agency Inspector(if present during testing): <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-UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: X Hydrostatic Vacuum F--'Other <br /> Test Equipment Used:Standard Tape Measure Equipment Resolution: <br /> Identify Spill Bucket (By Tank T1: 87 Blue Slave Fill T2: 87 Blue Master T3: 87 Blue Syphon T4: 91 Gold Fill <br /> Number, Stored Product, etc.) Fill Fill <br /> Bucket Installation Type: ❑Direct Bury ❑Direct Bury Direct Bury u 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" <br /> 12" <br /> Bucket Depth: 14" 121/2" 13 ''/2" 14" <br /> Wait time between applying <br /> vacuum/water and start of test: 1 mm. 1 min. 1 min. 1 min. <br /> Test Start Time(TO: 9:20a.m 9:13a.m 9:05a m 9:17a.m <br /> Initial Reading(RO: 12'/<" 10 '/z" 1 l '/<" <br /> 12" <br /> Test End Time(TF): I D:49a. I 10:49a.m 10:48a.m 10:49a.m <br /> Final Reading(RF): 12 3/," 10 %2" 11 '/<" 1295 <br /> Test Duration(TF—Tj: lhr.29min. I hr.36min. lhr.43min. lhr.32min. <br /> Change in Reading(RF-R,): 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 X Pass ❑ Fail X Pass ❑Fail <br /> Comments— (include information on t•e airs made prior to testing, and recommended follow-u or failed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby cerlt&that all the Information contained in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signat <br /> Date:03-27-09 <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 />