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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 tests(if <br /> applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. F.ICIL/TYL\IFORAIATION <br /> Facility Name: ARCO TRACY 83333 Date of Testing: 10/8/2012 <br /> Facility Address: 550 VALPICO RD TRACY CA <br /> Facility Contact: DENNIS A. Phone: 209-836-3327 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(ifpresent durui _q resting): TIIUY IRAN <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Toy i and Country Contractors <br /> Technician Conducting Test: LATHAM ZUBILLAGA <br /> Credentials: CSLB Contractor X ICC Service Tech. ❑SWRCB Tank Tester ❑Other(Specify) <br /> License Number(s): <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: X Hydrostatic Vacuum ❑Other(Specify) <br /> "fest Equipment Used:'PAPE MEASURE Equipment Resolution: 1/8" <br /> Identify Spill Bucket(Br Tank 1 87 1YEST 2-91 3--DIESEL 4 87 F:�S'1 <br /> Number.Stored PrOdUC I.etc.) <br /> Bucket Installation Type: Direct Bury Direct Bury ❑Direct Bury Direct Bury <br /> X Contained in Sump ❑Contained in Sump ❑Contained in Sump ❑Contained in Sum <br /> Bucket Diameter: -12" __12" =12" __12" <br /> Bucket Depth: a 12" a 12" a 12" __12" <br /> Wait time between applying I MIN 1 MIN 1 MIN 1 MIN <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 11:19 11:15 11:11 11:22 <br /> Initial Reading(Rt): 123/4 131/4 13 1/4 127/8 <br /> Test End Time(TF): 12:19 12:15 12:11 12:22 <br /> Final Reading(RF): 123/4 13 1/4 13 1/4 127/8 <br /> fest Duration(TF—Tj): 1 HR 1 HR 1 HR 1 HR <br /> Change in Reading(RF-Rj): 0 0 0 0 <br /> Pass/Fail Threshold or Criteria: 0 0 0 0 <br /> fest Result: X Pass []Fail X Pass ❑Fail X Pass ❑Fail X Pass ❑Fail <br /> Comments—(include inJiirntation on repairs made prior to teslhW,and tesis) <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:_ g L Date:_10/8/12 <br /> 1 State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements may be <br /> more stringent. <br /> 8 2/21/07 <br />