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ecq� <br /> Spill Bucket Testing Report Form <br /> This form is intended for use by contractors perlbrming annual testing of UST spill containment structures. The completed form and <br /> printouts from 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 I Date of Testing: 10/30/2014 <br /> Facility Address: 550 W.Valpico Road,Tracy,CA 95376 <br /> Facility Contact: Edgar Rizkalli I Phone: (925)548-7910 <br /> Date Local Agency Was Notified of Testing: 10/21/2014 <br /> Name of Local Agency Inspector(i/'present during testing): Elena Manzo <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: ECO-CHEK Compliance, Inc. <br /> Technician Conducting Test: Nik Zagorov <br /> Credentials: E CSLB Contractor E ICC Service Tech. E SWRCB Tank Tester ❑Other(Specify) <br /> License Number(s): 958763 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: E Hydrostatic ❑ Vacuum ❑Other <br /> Test Equipment Used:Tape Measure/Level Change Indicator Equipment Resolution: 1/16"/0.0025 <br /> Identify Spill Bucket(By Tank 1 87-E 2 87-W 391 4 Diesel <br /> Number, Stored Product, etc.) <br /> Bucket Installation Type: <br /> El Direct Bury ❑ Direct Bury El Direct Bury El Direct Bury <br /> ® Contained in Sum E Contained in Sum E Contained in Sum E Contained in Sum <br /> Bucket Diameter: 12 Inches 12 Inches 12 Inches 12 Inches <br /> Bucket Depth: 14 Inches 14 Inches 14 Inches 14 Inches <br /> Wait time between applying 10 Minutes 10 Minutes 10 Minutes 10 Minutes <br /> vacuum/water and start of test: <br /> Test Start Time(Tt): 11:55 AM 11:55 AM 02:05 PM 11:55 AM <br /> Initial Reading(Rt): 13 5/8 Inches 13 318 Inches 0 13 1/4 Inches <br /> Test End Time(TF): 12:55 PM 12:55 PM 02:35 PM 12:55 PM <br /> Final Reading(RF): 13 5/8 Inches 13 3/8 Inches 0 13 1/4 Inches <br /> Test Duration(TF—Tt): 60 Minutes 60 Minutes 30 Minutes 60 Minutes <br /> Change in Reading(RF-Rt): 0 Inches 0 Inches 0 0 Inches <br /> Pass/Fail Threshold or 1/16 Inches 1/16 Inches 0.0025 1116 Inches <br /> Criteria: <br /> Test Result: Pass ❑ Fail ® Pass ❑ Fail ® Pass ❑ Fail ® Pass ❑ Fail <br /> Comments— (include informutioti on repuirs made prior•to testing, and recommended folloir-np for,failed tests) <br /> Premium Tank Spill Bucket was retested with accelerated Level Change Indicator. <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: rC>V Date: 10/30/2014 <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 />