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F.0,Bux 4206 <br /> MHaz <br /> A <br /> lite <br /> Sonora CA 95370 <br /> A-Haz <br /> ch Pe <br /> t . Ca 6235�I1 <br /> Phnnr:2C9-532-112) <br /> Complioncc without Compromise lax:209-5J3-235U <br /> ma l�t)all:echpetrc.com <br /> -„,wks.all=chpetrc.com <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 Tank 1 87 Master Vapor 1 2 87 Master Vapor 2 3 87 Slave Vapor 4 91 Vapor <br /> Number,Stored Product,etc. <br /> ❑ <br /> Bucket Installation Type: Direct Bury El Direct Bury El 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,): Top of cap Top of cap Top of cap Top of cap <br /> Test End Time(TF): 14:25 14:24 14:20 14:26 <br /> Final Reading(RF): Top of cap Top of cap Tap of cap Top of cap <br /> Test Duration(tF—T,): 1.0 hr 1.0 hr 1.0 hr 1.0 hr <br /> Change in Reading(RF-R,): 0.0 0.0 0.0 0.0 <br /> Pass/Fail Threshold or Criteria: 1/16" 1/16" 1/16" 1/16" <br /> Test Result: ® Pass ❑Fail ® Pass ❑Fail ® Pass ❑Fail ® 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 />