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P.O.Box 4208 <br /> Sonora CA 95370 <br /> Afftech Ca 623541 A-Hoz <br /> Phone:209-532-7320 <br /> Compliance without Compromise Fax:209-533-2650 <br /> mail@alltechpetro.com <br /> www.alltechpetro.com <br /> Fill 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: Monday, February 11, 2013 <br /> Facility Address: 3212 N.California St. Stockton CA 95204 <br /> Facility Contact: Wendy Phone: 209-941-2694 <br /> Date Local Agency Was Notified of Testing : 1/23/13 <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 8146912-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 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,): 11:00 am 11:00 am 11:00 am 11:00 am <br /> Initial Reading (R,): 3"above cap 2"above cap 2.5"above cap 3.5"above cap <br /> Test End Time(Tr): 12:00 pm 12:00 pm 12:00 pm 12:00 pm <br /> Final Reading (Rr): 3"above cap 2"above cap 2.5"above cap 3.5"above cap <br /> Test Duration (Tr—Ti) 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 I ® Pass ❑Fail I ® Pass ❑ Fail I ® 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: 02/11/13 <br />