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Spill Bucket Testing Report Form <br /> This fibrin is intended for use by contractors performing annual testing of UST spill containment structures. The completed form and <br /> printouts.Ji•bm 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: ARCO AMPM Date of Testing: 1/15/2013 <br /> Facility Address: 130 S WILSON WAY City:STOCKTON <br /> Facility Contact: PARMJIT Phone: 416-4743 <br /> Date Local Agency Was Notified of Testing: Tuesday,January 08,2013 <br /> Name of Local Agency Inspector(if present during testing): ARIS CACAPIT <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: BZ Service Station Maintenance <br /> Technician Conducting Test: RHOME DESBIENS <br /> Credentials: 0 CSLB Contractor ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other(Specify) <br /> License Number(s): 433159 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br /> Test Equipment Used: RULER Equipment Resolution: 1/16" <br /> Identify Spill Bucket(lay Tank 1 87 MASTER 2 91 3 87 SLAVE 4 <br /> Number, Stored product, etc.) 11 <br /> Bucket Installation Type: ❑ Direct Bury ❑ Direct Bury ❑ Direct Bury ❑ Direct Bury <br /> ® Contained in Sum ®Contained in Sum ® Contained in Sum ❑ Contained in Sum <br /> Bucket Diameter: 1199 11" 11" <br /> Bucket Depth: 12.5" 12" 12.5" <br /> Wait time between applying 5 MIN 5 MIN 5 MIN <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 10:44 10:44 10:44 <br /> Initial Reading(Ri): 12.5" 12" 12" <br /> Test End Time(T,): 11:44 11:44 11:44 <br /> Final Reading(R,:): 12.5" 12" 12" <br /> Test Duration(TF—Ti): 1 HR 1 HR 1 HR <br /> Change in Reading(RF—Rj): 0 0 0 <br /> Pass/Fail Threshold or 0 0 0 <br /> Criteria: <br /> Test Result: ® Pass ❑ Fail ® Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail <br /> Comments— (include information on repairs made prior to testing, and recommended follow-tip 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: Date: 1/15/2013 <br /> State laws and re"ulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more <br /> stringent. <br /> Monitoring-Certification Test Report <br /> 4 of 4 <br />