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imGErrm-RYAN INC. 0 <br />20-64191 <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 SS 2093 Date of Testing: <br />Facility Address: 342.5 Tracy Blvd., Tracy, CA <br />Facility Contact: Sarah Samuels Phone: 360-526-3917 rl <br />Date Local Agency Was Notified of Testing: <br />Name of LocalAgency Inspector i present during testing): <br />Uri <br />Company Name: Gettler-Ryan Inc.. 6805 Sierra Court, Suite G. Dublin. Ca. 94568 Ph.# 925-551-7555 <br />Technician Conducting Test: Gilbert Garcia <br />Credentials: (1) CSLB Contractor ICC service Tech. SWRCB Tank Tester Other (Specify) <br />License Number: 220793 ICC Tech Number: 8211864 -IFF <br />Kim a I IN N alfeuq 516 1 X-3 I I N9ffkTfsT,,T3r M e' <br />Test Method Used: <br />Hvdrostatic <br />Vacuum <br />Other <br />Test Equipment Used: <br />Lake Test <br />Equipment Resolution: <br />1/16" <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc. <br />t Tl 87 <br />Fill <br />2 T2 87 <br />Fill <br />3 T3 87 <br />Fill <br />4 91 <br />Fill <br />Bucket Installation Type: <br />Direct Bury <br />x Contained in Sump <br />Direct Bury <br />x Contained in Sump <br />Direct Bury <br />x Contained in Sump <br />Direct Bury <br />x Contained in Sump <br />Bucket Diameter: <br />12" <br />12" <br />12" <br />12" <br />Bucket Depth: <br />14" <br />14" <br />14" <br />14" <br />Wait time between applying <br />vacuum/water and start of test: <br />Smin <br />Smin <br />Smin <br />Smin <br />Test Start Time (Ti): <br />9:30 <br />9:30 <br />9:30 <br />9:30 <br />Initial Reading (Ri): <br />12.5" <br />12.5" <br />12.5" <br />12.5" <br />Test End Time (Tf): <br />10:30 <br />10:30 <br />10:30 <br />10:30 <br />Final Reading (Rf) <br />12.5" <br />12.5" <br />12.5" <br />12.5" <br />Test duration (Tf-Ti): <br />l hr <br />lhr <br />lhr <br />lhr <br />Change in Reading (Rf-Ri): <br />0 <br />0 <br />0 <br />0 <br />Pass/Fail Threshold or Criteria: <br />0 <br />0 <br />0 <br />0 <br />Test Results: 11 <br />X Pass Fail <br />X Pass Fail <br />X Pass Fail <br />X Pass Fail <br />Comments - (include information on repairs made prior to testing, and recommended follow-up far 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: Date: 9/7/2016 <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 />