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GETTtFR-RYAN INC. GR Job# 17203106 <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 ownerloperator for submittal to the local regulatory agency. <br /> 1.FACILITY INFORMATION <br /> Facility Name: Arco 2093 Date of Testing: 9/6/2Oj2_ PON 0224 <br /> Facility Address: 3425 Tracy Blvd.,Tracy,CA <br /> Facility Contact: Daryl Lee Phone: 415-902-5089 1 IL L -- E= 11 <br /> Date Local Agency Was Notified of Testing: <br /> -Name of EmilAgency Inspector (if-present during testin <br /> 2.TESTING CONTRACTOR INFORMATION LT <br /> Company Name: Gettler-Ryan Inc.,6805 Sierra Court,Suite G,Dublin,Ca.94568 Ph.#925-551-7555 <br /> Technician Conducting Test: Gilbert Garcia ° Y <br /> Credentials:(1) CSLB Contractor ICC service Tech. SWRCB Tank Tester Other(Spec) <br /> License Number: 220793 ICC Tech Number: 8211864-1IT <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: Hydrostatic Vacuum Other <br /> Test Equipment Used: Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By Tank 1 87 Fill11 _I2 87 Fill 3 87 Fill 4 91 Fill <br /> Number,Stored Product,etc.) <br /> Bucket Installation Type: <br /> Direct Bury Direct Bury Direct Bury Direct Bury <br /> x Contained in Sump x Contained in Sump x Contained in Sump x Contained in Sump <br /> Bucket Diameter: 12" 12" 12" 12" <br /> Bucket Depth: 11" i l" 11" 11" <br /> Wait time between applying <br /> 5 min 5 min 5 min 5 min <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 9:00 9:00 9:00 9:00 <br /> Initial Reading(Ri): 9 7/8" 9 7/8" 10 1/4" 10 1/4" <br /> Test End Time(Tf): 10:00 10:00 10:00 10:00 <br /> Final Reading(Rf) 9 7/8" 9 7/8" 10 1/4" 10 1/4" <br /> Test duration(Tf-Ti): I hr l hr 1 hr lhr <br /> Change in Reading(Rf-Ri): 0 0 0 0 <br /> Pass/Fail Threshold or Criteria: 0 0 0 0 <br /> Test Results: X ,Pass Fail X Pass Fail I X Pass Fail X Pass Fail <br /> Comments-(include information on repairs made prior to testing,and recommended follow-up for failed tests) <br /> CERTFICATION 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: 14�� Date: 9/6/2017 <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 />