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6frTtfR-RrAN INc. R Job# 17200007 <br /> S WRCB,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 (:f applicable), should be provided to the facility owner/operator for submittal to he I�local/rggulgtory aen � <br /> 1. FACILITY INFORMATIONS <br /> Facility Name: Arco SS 2186Lj <br /> Date of Testing: 1/5/201? <br /> Facility Address: 3212 N.California,Stockton,CA F <br /> Facility Contact: Daryl Lee Phone: 415-902-5089 <br /> Date Local Agency Was Notified of Testing: <br /> Name OT LocalAgency inspector r presen urrng es in ENVIRONMENTAI dFALTH <br /> 2.TESTING CONTRACTOR INFORMATION DEPARTMENT <br /> CompanyName: Gettler-Ryan )nc..68 5 Sierra Court Suite ,Dublin,Ca.94568 Ph.#925-551_^,555 <br /> Technician Conducting Test: Tim Adams <br /> Credentials:(l) CSLB Contractor ICC service Tech. SWRCB Tank Tester Other(Specify) <br /> License umber: 220793 ICC Tech Number: 8205730 <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: li drostatic Vacuum Other <br /> Test Equipment Used: Standard Tape Measurer Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By Tank 1 87-1 Fill 2 87-1 Fill 3 87-2 Fill 4 91 Fill <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" 14" 14" <br /> Wait time between applying <br /> Smin Smin Smin Smin <br /> vacuum water and start of test: <br /> Test Start Time(Ti): 9:40 9:40 9:40 9:40 <br /> Initial Reading(Ri): 12.5" 12" 12" 12.5" <br /> Test End Time(Tf): 10:40 10:40 10:40 10:40 <br /> Final Reading(Ro 12,5" 12" 12" 12" <br /> Test duration(Tf-Ti): 1 hr I 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 /> 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: � ` S <br /> g 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 />