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e v/ <br /> L::u-GtGR CGwPtfttCt <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: 10/31/2013 <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: 10/19/2013 <br /> Name of Local Agency Inspector(if present during testing): Thuy Tran <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: ECO-CHEK Compliance <br /> Technician Conducting Test: Nik Zagorov <br /> Credentials: Z CSLB Contractor Z ICC Service Tech. Z SWRCB Tank Tester ❑ Other(Spec) <br /> License Number(s): 958763 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: Z Hydrostatic ❑ Vacuum ❑Other <br /> Test Equipment Used: Tape Measure Equipment Resolution: 1/16 Inches <br /> Identify Spill Bucket(By Tank 1 87-E 2 87-W 391 4 Diesel <br /> Number, Stored Product, etc.) <br /> Bucket Installation Type: ❑ Direct Bury ❑ Direct Bury ❑ Direct Bury ❑ Direct Bury <br /> Z Contained in Sump Z Contained in Sump Z Contained in Sump Z Contained in Sum <br /> Bucket Diameter: 12 Inches 12 Inches 12 Inches <br /> Bucket Depth: 14 Inches 14 Inches 14 Inches <br /> Wait time between applying 10 Minutes 10 Minutes 10 Minutes <br /> vacuum/water and start of test: <br /> Test Start Time(Tj): 09:10 AM 09:10 AM 09:10 AM <br /> Initial Reading(R,): 11 Inches 11 Inches 11 Inches <br /> Test End Time(TF): 10:10 AM 10:10 AM 10:10 AM <br /> Final Reading(RF): 11 Inches 11 Inches 11 Inches <br /> Test Duration(TF—T,): 60 Minutes 60 Minutes 60 Minutes <br /> Change in Reading(RF-R,): 0 Inches 0 Inches 0 Inches <br /> Pass/Fail Threshold or 1116 Inches 1/16 Inches 1/16 Inches <br /> Criteria: <br /> Test Result: ® Pass ❑ Fail ® Pass ❑ Fail I ® Pass ❑ Fail ❑ Pass ❑ Fail <br /> Comments— (include information on repairs made prior to testing, and recommended follow•-itp for foiled tests) <br /> Diesel Tank Spill Bucket was not tested. Diesel Tank out of service. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> 1 hereby certify that all the information contained in this report is true,accurate,and in frill compliance with legal requirements. <br /> Technician's Signature: t13 r 0V Date: 10/31/2013 <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 />