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04/10/2015 7: 18AM FAX 19252E 71 Guadalupe Sanchez R0015/0015 <br /> SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intended for use by contractors performing annual testing of USTspill 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 Datc of Testing; 03/10/2015 <br /> Facility Address: 25775 So.Patterson Rd.,Tracy,Ca.95376 <br /> Facility Contact: Neil Patel Phone: (510)299-1219 <br /> Date Local Agency Was Notified of Testing: Fatinah 7_areef <br /> Name of Local Agency Inspector(ifpresent 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. 0 SWRCB Tank Tester 0 Other(Spee) <br /> License Number(s): 883706 5250451-UT <br /> 3. SPILL BUCKET TESTING INFORMATION _ <br /> Test Method Used: xHydrostatic 1 1 Vacuum ❑Other <br /> Test Equipment Used: Standard Tape Measure Liquipment Resolution:N/A <br /> identify Spill Bucket(By Tank 1 TI: 87 Stave Fill 2 T2:87 Master Fill 3 T3: 87 Siphon 4 T4:91 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 x Contained in Sump xContained in Sum <br /> Bucket Diameter: 12" 12" 12" -- 12" <br /> Bucket Depth: 14" 14" 13'/4" 131/21, <br /> Wait time between applying 1 minute 1 minute 1 minute I minute <br /> vacuum/water and start of test: <br /> 'fest Start Time(T,): 11:20 a.m. 11:20 a.m. 11:20 a.m. 1120 a.m. <br /> Initial Reading(R,): 12 5/8" 12'/." 12'/a" 123/81, <br /> Test End Time(TF): 12:20 p.m. 12:20 p.m. 12:20 p.m. 12:20 p.m. <br /> Final Reading(Rp): 12 5/8" 12'/T 12%z" 12 3/8" <br /> Test Duration(TF—T,): 1 hr 1 hr 1 hr 1 hr <br /> Change in Reading(RF-R,): 0 0 0 0 <br /> Pass/Fail Threshold or 1/16" 1/16" 1/16" 1/16" <br /> Criteria: <br /> Teat Result: x Pass ❑Fall x Pass D Fall x Pass ❑Fail x Pass ❑P'ail <br /> Comments—(include irfnrmation on repairs made prior to testing, and recommended follow-up forfailed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the information contained in thin report Ls true,accurate,and in full compliance with legal requirements. <br /> Technician's Signatur _ ,� Date 03/10/2015 <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 />