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Spill Bucket Testing Report Form <br />Th is is intendsdoor rise hY c°c�ntractars Jc>rfc�rrrrin r crnntrc7t lvstin refL'ST sf�ill x-oniainment siructurc.s. The completed,f6rrrt and <br />printouts from le,sts (ff'applicahle), should her provided to the fuc~ilitc ownerl"operator fire submittal ro the local regulatory ai,=enc'y, <br />1. C H.t,.i.a 1 Z ltr,c VX�.irits ■ iva. <br />Facility Name: ARCO AMPM Dare «f'I'estang: 9f23/2014 <br />Facility Address: 880 E VICTOR R1) Citi: LOT)I <br />._...... <br />Facility Contact: KARAN Phone: 209-369-098 <br />Date local Agency Was Notified of Testing Wednesday, Au ust 20, 2014 <br />_. <br />Name of Local Agency inspector (present during testing): <br />2. TESTING CONTRACTOR INFORMATION m <br />R <br />Company Name: RZService Station Maintenance �..,..._ __......._._._ _........ _._ _.... <br />..._ <br />Technician Conducting Test ALEXANDER TATE <br />C're€ientiatls�����s':N CISIA3 Contractor lC C; ;�crvice °x`ech. SWR f3 7�ank I ester ❑ Other t�a�ec ifi�i <br />License Number(s): 433159 <br />3. SPI LI., BUCKET TESTING INFORMATION <br />Test Method Used <br />HydrostaticQ -racaa, , e'.._. __ _ _ <br />Test Equipment Used: TAPE. MEASURE <br />Equipment Resolution ltlh" <br />l <br />identify Spill Bucket (4y Tank <br />1 'T'I-87 2 T2-91 3 T3-ll►4T. f 4 <br />��fumber; tora:cif'rodrtet, etc_f <br />Direct Bury i Direct. Bury j Direct BL Direct Bury <br />Bucket Installation Type: <br />❑ Contained in Stam [Mj Contained in Sunt ! ®C'ontained in Sutra [� Contained to �ittntl? <br />Bucket f)iameter: <br />1.1" <br />11" <br />11 �• <br />Depth: <br />13.25" <br />11" <br />13„ <br />�Buckt�,t <br />aitme between applying, <br />5MIN <br />5 MIN <br />5 MIN <br />cuuv water and start of test:- <br />�_ <br />Test Start. Time (Ti): <br />9:40 <br />9:40 <br />9:40 <br />Initial Reading (Rj): <br />13.25" <br />p 1" <br />13" <br />1'est End Time ('I'u): <br />10:40 <br />1(t <br />tfA <br />Final Reading (Rt ): <br />13.25 <br />_...._..._. _ <br />11 <br />__._.. .__ .. _ .._ .._ ...__ <br />___......... _....... <br />_ ----------- <br />Test Duration (Tr: Ti): <br />1 11R <br />1 [112 __ ................_........._.__. <br />__ _.__ �o <br />.__ . __ W . <br />_................ ._.__.._..... - ............................-__ .. <br />Change in Reading (Rr- Ri): <br />0 <br />0 <br />FAIL <br />Pass/Fail Threshold or <br />0 <br />0 <br />0 <br />Criteria: <br />Passµ Z Fail <br />1 Pass Fat <br />Test ResultPass]i1 <br />'ass ] Eapp <br />E r, t "I <br />OPW BUCKET'S <br />can repairs mace prier to <br />DSL BUCKETFAILED, D, .NEED TO REPAIR AND RETESTE <br />, crxacf rec•ummc n<tc�cr <br />f�11'l L7Nd (f f4?!v <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THISTESTING <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: <br />' State latus and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more <br />stringent. <br />Monitoring Certification Test Report <br />4 of':i <br />