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GFrrIEB-RYAN INC. GR Job# 17203105 <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: <br /> so D <br /> Facility Address: 3425 Tracy Blvd..Tracy,CA <br /> Facility Contact: Daryl Lee Phone: 411-1-902-5089 <br /> Date Local Agency Was Notified of Testing: ULT <br /> Name of LocalAgency nspectori present during testing): <br /> 2.TESTING CONTRACTOR INFORMATION ENVIRONMENTAL HEALTH <br /> Company Name: Gettler-Ryan Inc.,6805 Sierra Court,Suite G,Dublin,Ca.94568 PhX 925-551-7555 DEPARTMENT <br /> Technician Conducting Test: Gilbert Garcia <br /> Credentials:(1) CSLB Contractor ICC service Tech. SWRCB Tank Tester Other(Specie) <br /> License Number: 220793 ICC Tech Number: 8211864-UT <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: Hydrostatic Vacuum Other <br /> Test Equipment Used: Standard Tape Measurer Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By Tank 1 87 2 87 3 87 4 91 <br /> Number,Stored Product,etc.) Vapor Va or ``a or Va or <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: lift 11" Ill, Ill, <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): 10" 10" JO" 10" <br /> Test End Time(Tf): 10:00 10:00 10:00 10:00 <br /> Final Reading(Rf) 10" 10" 10" 10" <br /> Test duration(Tf-Ti): lhr 1hr 1hr 1hr <br /> Change in Reading(Rf-Ri): 0 0 0 0 <br /> Pass/Fail Threshold or Criteria: 0 0 0 0 <br /> Test Results: if X Pass Fall X Pass Fail X Pass Fail X Pass Fail <br /> Comments-(include information on repairs made prior to testing,and recommended follow-up for failed tests) <br /> CERTIFICATION 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 /> i <br /> Technician's Signature: ii4Date: 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 />