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Fjj C1fTTIfR-RYAN INC. ,R Job# 17200007 <br /> 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 SS 2136 Date of Testi : 1 rl `n <br /> Facility Address: 3212 N.California,Stockton,CA <br /> Facility Contact: Daryl Lee Phone: 415-902-5089 <br /> Date Local Agency Was Notified of Testing: <br /> Name of LocalAgency nspector(i present during testing): <br /> 2.TESTING CONTRACTOR INFORMATION ENVIRONMENTAL HEALTH <br /> Company Name: Gettler-Ryan Inc.,6805 Sierra Court Suite G,Dublin,Ca.94568 Ph.9 925-5_>1-755.5 _r�..,.,-,, 7 a 1 ,,,-7, i <br /> Technician Conducting Test: Tim Adams <br /> Credentials:(I) CSLB Contractor ICC service Tech. SWRCB Tank Tester Other(Specify) <br /> License Number: 220793 ICC Tech Number: 8205730 <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: H-,druatatic Vacuum Other <br /> Test Equipment Used: Standard Tape;Measurer Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By Tank 1 87-1 Vapor 2 87-1 Vapor 3 87-2 Vapor4 91 Vapor <br /> Number,Stored Product, etc.) <br /> Bucket Installation Type: <br /> Direct Bury Direct Bury Direct Bury Direct Bury <br /> x Contained in Sump x Contained in Sump x Contained in Sump x Contained in Sump <br /> Bucket Diameter: 12" 12" 12" 12" <br /> Bucket Depth: 14" 14" 141, 14" <br /> Wait time between applying <br /> Stain 5min Satin .5min <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 9:50 9:50 9:50 9:50 <br /> Initial Reading(Ri): 13" 13" 13" 13" <br /> Test End Time(Tf): 10:50 10:50 10:.50 10:50 <br /> Final Reading(Rf) 13" 13" 13" 13" <br /> Test duration(Tf-Ti): 1 hr 1 hr 1 hr 1 hr <br /> Change in Reading(Rf-Ri): 0 0 0 0 <br /> Pass/Fail Threshold or Criteria: 0 0 0 0 <br /> Test Results: 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 /> CERTFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> J hereby certify that all the information contained in this report is true,accurate,and in full compliance with legal requirements <br /> c_ <br /> Technician's Signature: S' Date: 1/5/2017 <br /> (1) 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 />