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P.O.Box 4208 <br /> Sonora CA 95370 <br /> Ca:623541 A-Haz <br /> AlitechPed"5- Phone:209-532-7320 <br /> Compliance without Compromise Fax:209-533-2650 <br /> mail@ailtechpetro.com <br /> www.alltech petro.com <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 printouts from <br /> 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 2133 Date of Testing: Wednesday,January 23,2013 <br /> Facility Address: 2908 Benjamin Holt Dr.Stockton,CA 95207 <br /> Facility Contact: Laurence Phone: 209-478-5552 <br /> Date Local Agency Was Notified of Testing: 12/20/12 <br /> Name of Local Agency Inspector(if present during testing): Jeff Wong <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Alltech Petro Inc,P.O.Box 4208,Sonora CA 95370.(209)532-7320 <br /> Technician Conducting Test: Chad White <br /> Credentials': ®CSLB Contractor ®ICC Service Tech. ®SWRCB Tank Tester ❑Other(Specify) <br /> License Number(s): CA:623541 A-Haz ICC 8152115-UT SWRCB 09-1747 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ®Hydrostatic ❑Vacuum C Other <br /> Test Equipment Used: One Hour observed test Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By Tank 1 87 Master Fill 2 87 Slave Fill 3 91 Fill 4 <br /> Number,Stored Product,etc. <br /> Bucket Installation Type: ❑Direct Bury Dinect,Zury Direct'Bury ❑ Direct Bury <br /> ®In Sum1rt� rfbi trtSu" LlIn Sum <br /> Wait time between applying <br /> vacuum/water and start of 0 0 0 <br /> test: <br /> Test StartTime(T,): 10:20 10:20 <br /> Initial Reading(R,): 2 1/2"above cap 2 3/4"above cap 3 1/4"above cap <br /> Test End Time(TF): 11:20 11:20 11:20 <br /> Final Reading(RF): 2 1/2"above cap 2 3/4"above cap 3 1/4"above cap <br /> Test Duration(TF—T,): 1.0 hr 1.0 hr 1.0 hr <br /> Change in Reading(RF-R,): 0.0 0.0 0.0,.�`. <br /> Pass/Fail Threshold or Criteria: 1/16" 1/16" 1/16" <br /> est ,. ® PslSS ®.Fad !Past` l!44 , ;;I' - ❑ ,Pass fail <br /> Comments—(include information on repairs made prior to testing,;and recommerideal folloJ�i=up fof failed <br /> tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIB FOR E 1 NDU�,THtSTESTING <br /> 4I hereby certify that all the information contained in this report Tran;aCcarate,&ra�i�i full c r7s/fance with legal requirements. <br /> Technician's Signature: Date: 13/13 <br />