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SWRCB,January 2006 <br /> 9. 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 /> FacilityName: ARCO #06080, CC 18022649 DateofTesting: 09/27/2007 <br /> Facility Address: 85 E LOUISE AVE PTO N-71, LATHROP, CA, 95330 <br /> Facility Contact: MANGER Phone: (2 04) 983-9144 <br /> Date Local Agency Was Notified of Testing: 08/30/2007 <br /> Name of Local Agency Inspector(if present during testing): TOUR YANY <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: JOEY MESA <br /> Credentials :❑CSLB Contractor E ICC Service Tech. ❑SWRCB Tank Tester E Other(Specify) ICC SERVICE <br /> License Number: 5259458-UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: El Hydrostatic Vacuum El Other <br /> Test Equipment Used:TAPE MEASURE Equipment Resolution:VISUAL LOSS <br /> Identify Spill Bucket(By Tank 1 1 REG FILL 2 2 PLU FILL 3 3 PRE FILL 4 <br /> Number,Stored Product,etc) <br /> Direct Bury ❑Direct Bury Direct Bury ❑ Direct Bury <br /> Bucket Installation Type': X❑Contained in SumpX❑Contained in SumpXO Contained in Sump ❑Contained in Sump <br /> Bucket Diameter: 1 1211 1211 1211 <br /> Bucket Depth: 1411 141- 1411 <br /> Wait time between applying 5 MIN. 5 MIN. 5 MIN. <br /> vacuum/water and starting test: <br /> Test Start Time(TI ): 12 :4 5 12:45 12:45 <br /> Initial Reading(RI ): <br /> 13" 13" 13" <br /> Test End Time(TF): 13 :50 13:50 13:50 <br /> Final Reading(RF ): 13" 1311 1311 <br /> Test Duration: 60 MIN. 60 MIN. 60 MIN. <br /> Change in Reading(R F-RI ): <br /> 0" 0" 0" <br /> Pass/Fail Threshold or VISUAL LOSS VISUAL LOSS VISUAL LOSS <br /> Criteria: <br /> Test Result: x Pass ❑ Fail ElPassD Fail Pass Fail ElPass Fai( <br /> Comments- (include inf n-mation on repairs made prior ro lesrilw, -upf)r fcfiled tests) <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 full compliance with legal requirements. <br /> Technician's Signature: Date:Date: 09/27/2007 <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 />