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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(f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Arco I Date of Testing: 03/31/2011 <br /> Facility Address: 1100 S.Main St.Manteca,Ca.95337 <br /> Facility Contact: Jessie Phone: 209-609-0117 <br /> Date Local Agency Was Notified of Testing: __ D —// <br /> Name of Local Agency Inspector(fpresent during testing): /yl u n j IVAj u <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Reliable Petroleum Services Inc. <br /> Technician Conducting Test: Guadalupe Sanchez <br /> Credentials': x CSLB Contractor x ICC Service Tech. ❑SWRCB Tank Tester ❑Other(Spec) <br /> License Number(s): 883706 5250451-UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: xHydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used: Standard Tape Measure Equipment Resolution:N/A <br /> Idents Spill Bucket Tank 1 T1: 87 Fill 2 T2 <br /> Identify P BY : 91 Fill 3 T3: 89 Fill 4 T4: <br /> Number, Stored Product, etc. <br /> Bucket Installation Type: Direct Bury Direct Bury Direct Bury Direct Bury <br /> x Contained in Sump x Contained in Sump x Contained in Sump ❑Contained in Sum <br /> Bucket Diameter: 12" 12" 12" <br /> Bucket Depth: 1 151/4" 151/4" 15 ''/z" <br /> Wait time between applying 1 minute 1 minute 1 minute <br /> vacuum/water and start of test: <br /> Test Start Time(T,): 3:00 p.m. 3:00 p.m. 3:00 p.m. <br /> Initial Reading(RI): 13 %i" 13 3/4" 13 %" <br /> Test End Time(TF): 4:00 p.m. 4:00 p.m. 4:00 p.m. <br /> Final Reading(RF): 13 ''/2" 133/4" 13 'h" <br /> Test Duration(TF—Tj): 1 hr 1 hr 1 hr <br /> Change in Reading(RF-RO: 0 0 0 <br /> Pass/Fail Threshold or 1/16" <br /> Criteria: <br /> Test Result: x Pass ❑Fail x Pass ❑Fail x Pass ❑Fail Pass ❑Fail <br /> Comments—(include information on repairs made prior to testing and recommended follow-up for failed 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 03/31/2011 <br /> ' 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 />