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®GfTUEE-RYAN INC. GR Job# 1820- 0072 <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 (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 6080 Date of Testing: 1/29/2018 <br /> Facility Address: 85 E. Louise Ave Lathrop 95330 <br /> Facility Contact: Dar 1 Lee Phone: 415-902-5089 <br /> Date Local Agency Was Notified of Testing: <br /> ame of Focalgency nspector i present during testing) <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: Gettler-Ryan Inc.,6805 Sierra Court,Suite G,Dublin,Ca.94568 Ph.#925-551-7555 <br /> Technician Conducting Test: Davi( Rouse <br /> Credentials:(1) CSLB Contractor ICC service Tech. SWRCB Tank Tester Other(Specify) <br /> License Number: 220793 ICC Tech Number: <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: Hvdrostatic Vacuum Other <br /> Test Equipment Used: Standard Tape Measurer Equipment Resolution: 1/16 <br /> Identity Spill Bucket(By Tank 1 2 3 4 <br /> Number,Stored Product,etc) 87 Vapor 91 Vapor 87 Vapor <br /> Bucket Installation Type: <br /> irect Bury LjDirect Bury irect Bury Lpirect Bury <br /> ontained in Sump ❑X Contained in Sump XOContained in Sump contained in Sump <br /> Bucket Diameter: 1211 12" 1211 <br /> Bucket Depth: 1411 1411 14" <br /> Wait time between applying <br /> vacuum/water and start of test: 5 mins 5 mins 5 mins <br /> Test Start Time(Ti): 9 :45 am 9 :45 am 9 :45 am <br /> Initial Reading(Ri): 1211 1211 1211 <br /> Test End Time(Tf): 10 :45 10 :45 1075 <br /> Final Reading(Rf) 1211 12" 1211 <br /> Test duration(Tf-Ti): 1 Hour 1 Hour 1 Hour <br /> Change in Reading(Rf-Ri): 0 0 0 <br /> Pass/Fail Threshold or Criteria: 0 0 0 0 <br /> Test Results: Q Pass uEad MUSS DEall Pass DERil I QPass ail <br /> Comments- include information on repairs made prior to testinz and recommendedfollow-up or ailed tests <br /> CERTFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the information contai ed int repor[is true,accurate,and in full compliance with legal requirements <br /> Technician's Signature: Date: 1/29/2018 <br /> (1) 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 />