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P.O.Bum 4266 <br /> AlitechPeti , Sonora CA9532.) <br /> _ Ca 623541 MHaz <br /> pfione:2L'9-53 2-!d 2:1 <br /> Compliance without Compromise Idx:209-5J3-2b5U <br /> ma 4:)a11-.3chpetrc.com <br /> -Jvr.alt_e<hpetrc.corn <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 printouts from <br /> 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: Tuesday,February 14,2012 <br /> Facility Address: 3212 N.California St. <br /> Facility Contact: Phone: 209-941-2694 <br /> Date Local Agency Was Notified of Testing <br /> Name of Local Agency Inspector(if present during testing): Garrett Backus <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Alltech Petro Inc,P.O.Box 4208,Sonora CA 95370.(209)532-7320 <br /> Technician Conducting Test: Isaac Anderson <br /> Credentials': ®CSLB Contractor ®ICC Service Tech. ®SWRCB Tank Tester ❑Other(Specify) <br /> License Number(s): CA:623541 A-Haz ICC 8005930-UT SWRCB 09-1749 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ® Hydrostatic ❑Vacuum ❑ Other <br /> Test Equipment Used: One Hour observed test Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By Tank1 87 Master Fill 1 2 87 Master Fill 2 3 87 Slave Fill 4 91 Fill <br /> Number,Stored Product,etc.) <br /> Bucket Installation Type: ❑ Direct Bury ❑ Direct Bury ❑ Direct Bury ❑ Direct Bury <br /> ®In Sump ®In Sump ®In Sump In Sum <br /> Wait time between applying <br /> vacuum/water and start of 0 0 0 0 <br /> test: <br /> Test Start Time(T,): 13:25 13:24 13:20 13:26 <br /> Initial Reading(R): 3 1/4"above cap 3 3/8"above cap 2 3/4"above cap 2 1/4"above cap <br /> Test End Time(TF): 14:25 14:24 14:20 14:26 <br /> Final Reading(RF): 3 1/4"above cap 3 3/8"above cap 2 3/4"above cap 2 1/4"above cap <br /> Test Duration RF—Ti): 1.0 hr 1.0 hr 1.0 hr 1.0 hr <br /> Change in Reading(RF-Rj): 0.0 0.0 0.00.0 <br /> Pass/Fail Threshold or Criteria: 1/16" 1/16" 1/16" 1/16" <br /> Test Result: ® Pass ❑Fail 1 ® Pass ❑Fail 1 ® Pass ❑Fail 1 ® Pass ❑Fail <br /> Comments— (include information on repairs made prior to testing, and recommended follow-up for failed <br /> 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: 2/14/12 <br />