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SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> 77tis form is intendedfor use by contractors pet forming annttal testing of UST spill containment siructtn•es.The completed form and printouts front tests(if <br /> applicable),should be provided to the facility owner/operator for submittal to the local regtdatoty agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Arco 5450 Date of Testing: 9/23/2010 <br /> Facility Address: Streetj 1617 W.Fremont St. CITY:Stockton California <br /> Facility Contact: IKelly Phone: 209)462-1617 <br /> Date Local Agency Was Notified of Testing: 9/14/2010 <br /> Name of Local Agency Ins ector i resent durtng testing): Ray Von Flue <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Wa lne Per- <br /> Technician Conducting Test: j Brandon Smith <br /> Credentials: CSLB Contractor 0 ICC Service Tech. ❑ SWRCB Tank Tester <br /> License Number(s): 300345 ❑ Other(Specify) <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ' Hydrostatic L1 Vacuum ❑ Other S eci <br /> Test Equipment Used: Visual Tape reading Equipment Resolution: <br /> Identify Spill Bucket(By Tank 87 Main 87 Aux 91 <br /> Number Stored Product etc.) El Fill ❑ Vapor f[D Fill ❑ Vapor Fill ❑ Vapor ❑ Fill ❑ Vapor <br /> ❑ Direct Bury ❑ Direct Bury Direct Bury Direct Bury <br /> Bucket Installation Type: 21 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/water and start of test: 15 Minutes 15 Minutes 15 Minutes <br /> Test Start Time(Tj): 12:00 12:00 12:00 <br /> initial Reading(Rt):Inches 9.5 9.5 9.5 <br /> Test End Time(TF): 13:00 13:00 13:00 <br /> Final Reading(RF):Inches 9.5 9.5 9.5 <br /> Test Duration(TF—Tt): 1 HOUR 1 HOUR 1 HOUR <br /> Change in Reading(RF-Rj): 0 0 0 <br /> Pass/Fail Threshold or Criteria: 0 0 0 <br /> est Result: Q Pass LJ Fail Pass ❑ Fail Pass ❑ Fail ❑ Pass ❑ Fait <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 /> 7 hereby certify that all the information contained in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: lJ " v Date: 9/23/2010 <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 />