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ddlL <br /> SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This forst is intended for use by contractors perforating annual testing of UST spill containment structures.The completed form and printouts from tests(if <br /> applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> I. FACILITY INFORMATION <br /> Facility Name: Arco 5450 Date of Testis : 9/23/2010 <br /> Facility Address: Street: 1617 W.Fremont St. CITY:Stockton California <br /> Facility Contact: Kelly Phone: 209 462-1617 <br /> Date Local Agency Was Notified of Testing: 9/14/2010 <br /> Name of Local Agency Ins ector i resent duritig testing) Ray Von Flue <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: lWayne Perry <br /> Technician Conducting Test: I Brandon Smith <br /> Credentials: CSLB Contractor El ICC Service Tech. ❑ SWRCB Tank Tester <br /> License Number(s): 300345 ❑ Other(Specify) <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: El Hydrostatic ❑ Vacuum ❑ Other S eci r <br /> Test Equipment Used: Visual Tape readin JEquipinent Resolution: <br /> =MsmaeU424 .34= Wit. <br /> Identify Spill Bucket(By Tank 87 Main 87 Aux _ 91 <br /> Number Stored Product etc.) ❑ Fill 21 Vapor ❑ Fill 0 Vapor ❑ Fill Ul Vapor ❑ Fill ❑ Vapor <br /> ❑ Direct Bury ❑ Direct Bury ❑ Direct Bu Direct Bury <br /> Buckel Installation Type: El Contained in Sump Contained in Sump Contained in Sump Contained in Sum <br /> Bucket Diameter: 12 12 12 <br /> Bucket Depth: 13 13 13 <br /> Wait time between applying <br /> vacuum/waler and start of test: 15 Minutes 15 Minutes 15 Minutes <br /> Test Start Time(TI): 14:00 14:00 14:00 <br /> Initial Reading(Ru):inches 9.50 10.00 9.00 <br /> Test End Time(Tr): 15:00 15:00 15:00 <br /> Final Reading(RF):Inches 9.50 10.00 9.00 <br /> est Dural on(Tr—Tl): 1 HOUR 1 HOUR 1 HOUR <br /> Change in Reading(RF-Rt): 0 0 0 <br /> Pass/Fail Threshold or Criteria: 0 0 0 <br /> Test Result: ' Pass Fail ' Pass Fail ' Pass LJ Fail U Pass LJ Fail <br /> Comments—(include infornration on repairs made prior to testing,and reconttnended follow-ap for jailed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify flint all the information contained in this report is trite,accurate,and in fill conrp0arrce with legal requirements. <br /> Technician's Signature: .'•• "'' Date: 9123/2010 <br /> State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements may be more stringent. <br /> b <br />