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w <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(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: 03/30/2012 <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: 015 -Z <br /> Name of Local Agency Inspector(f present during testing): Muniappa Naidu <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. D SWRCB Tank Tester ❑Other(Spec) <br /> License Number(s): 883706 5250451-UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: xHydrostatic D Vacuum D Other <br /> Test Equipment Used: Standard Tape Measure — Equipment Resolution:N/A <br /> Identify. ;. ;.... .. .: �:..., .., ,...: .,.. .. <br /> Spill Bucket(By Tank I Tl: 87 Fill(West) 2 TI:87 Fill(East) 3 T2: 91 Fill 4 T3: 89 Fill <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 Sunip x Contained in Sump x Contained in Sum <br /> Bucket Diameter: 12" 12" 12" 12" <br /> Bucket Depth: 14 '/2" 151/2" 153/4" 15 ''/z" <br /> Wait time between applying 1 minute I minute 1 minute 1 minute <br /> vacuum/water and start of test: <br /> Test Start Time(Tj): 12:35 p.m. 12:35 p.m. 12:36 p.m. 12:34 p.m. <br /> Initial Reading(R,): 12 5/8" 13 3/4" 14'/4" 13 3/4" <br /> Test End Time(TF): 1:35 p.m. 1:35 p.m. 1:36 p.m. 1:34 p.m. <br /> Final Reading(RF): 12 5/8" 133/4" 14'/4" 13 3/4" <br /> Test Duration(TF—Tj): 1 hr lhr 1 hr 1 hr <br /> Change in Reading(RF-RI): 0 0 0 0 <br /> Pass/Fail Threshold or 1/16" 1/16" 1/16" 1/16" <br /> Criteria: <br /> Test Result: x Pass D Fail x Pass D Fail z Pass D Fail x 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 Signa R Date 03/30/2012 <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 />