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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: Arco#2186 Date of Testing: 3/6/09 <br /> Facility Address: 3212 N California St.,Stockton Ca <br /> Facility Contact: Attendant Phone: (209)941-2694 <br /> Date Local Agency Was Notified of Testing: N/A <br /> Name of Local Agency Inspector(if present during testing): N/A <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Gettler-Ryan Inc <br /> Technician Conducting Test: Chris San Nicolas <br /> Credentials: X CSLB Contractor ❑ICC Service Tech. SWRCB Tank Tester 0 Other(Specify) <br /> License Number(s): 220793 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: X Hydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used: Tape Measure Equipment Resolution:1/16" <br /> Identify Spill Bucket(By Tank 1-87 Master 2-87 Master 3-87 Siphon 4-91 <br /> Number, Stared Product, etc. <br /> Bucket Installation Type: 0 Direct Bury ❑Direct Bury ❑Direct Bury ❑Direct Bury <br /> X Contained in Sump X Contained in Sump X Contained in Sump X Contained in Sum <br /> Bucket Diameter: 12" 12" 12" 12" <br /> Bucket Depth: 13" 13" 13" 13" <br /> Wait time between applying 15 min 15 min 15 min 15 min <br /> vacuum/water and start of test: <br /> Test Start Time(Tj): I l:00am 11:00am 11:00am 11:00am <br /> Initial Reading(Ri): 9" 9" 9" 9" <br /> Test End Time(TF): 12:00pm 12:00pm 12:00pm 12:00pm <br /> Final Reading(RF): 9" 9" 9" 9" <br /> Test Duration(TF—Ti): 1 hr 1 hr I hr 1 hr <br /> Change in Reading(RF-Ri): 0 0 0 0 <br /> Pass/Fail Threshold or 0 0 0 0 <br /> Criteria: <br /> Test Result: X Pass ❑Fail X Pass ❑Fail X Pass ❑Fail X 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: Date: <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 />