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SWRCB, January 2006 <br />Spill Bucket Testing Report Form <br />Tltis forun is intended for use by contractors performing attmtal testing of UST spill containment structures. The completed form and printouts from tests (if <br />applicable), should be provided to thefacility otuner/operatw'forsubmittal to the local regulatory agency. <br />1. FACILITV INFORMATION <br />Facility Name: Arco 5450 <br />Date of Testin : 9/23/2010 <br />Facility Address: Street: 11617 W, Fremont St. <br />CITY: Stockton California <br />Facility Contact: IKelly <br />Phone: 209 462-1617 <br />Date Local Agency Was Notified of Testing : 9/14/2010 <br />Name of Local Agency Ins ector i resent during testing) <br />Ray Von Flue <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: Wayne Perry <br />87 Aux <br />❑ Fill 0 Vapor <br />Technician Conductin Test: Brandon Smith <br />Credentials: CSLB Contractor El ICC Service Tech. ❑ <br />SWRCB Tank Tester <br />License Number(s): 300345 <br />❑ Other (Specify) <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: <br />� H drostatic <br />El Vacuum <br />0 Other (Specify) <br />Test Equipment Used: <br />Visual Tape reading <br />Equipment Resolution: <br />Identify Spill Bucket (By Tank <br />Number. Stored Product, etc. <br />87 Main <br />❑ Fill 0 Vapor <br />87 Aux <br />❑ Fill 0 Vapor <br />91 <br />❑ Fill 0 Vapor <br />❑ Fill ❑ Vapor <br />Bucket Installation T <br />❑ Direct Bu <br />Contained in Sump <br />❑ Direct Bury <br />0 Contained in Sump <br />❑ Direct Bury <br />Direct Bury <br />Contained in Sump <br />Contained in Sump <br />Bucket Diameter: <br />12 <br />12 <br />12 <br />Bucket Depth: <br />13 <br />13 <br />13 <br />Wait time between applying <br />vacuum/water and start of test: <br />15 Minutes <br />15 Minutes <br />15 Minutes <br />Test Start Time (Tt): <br />14:00 <br />14:00 <br />14:00 <br />Initial Reading (Rt): Incites <br />9.50 <br />10.00 <br />9.00 <br />Test End Time (Tr): <br />15:00 <br />15:00 <br />15:00 <br />Final Reading(Rr): Inches <br />9.50 <br />10.00 <br />9.00 <br />Test Dural on (TF—Tt): <br />1 HOUR <br />1 HOUR <br />1 HOUR <br />Change in Reading (Rte -R): <br />0 <br />0 <br />0 <br />Pass/Fail Threshold or Criteria: <br />0 <br />0 <br />0 <br />Test Result; <br />' Pass, Fail , <br />' Pass Fflil <br />' Pass Fail <br />I'flS8' Fflil <br />Comments — (include information on repairs made prior to testing, and reconnatended follow-itp for failed tests) <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />I hereby certify that til the infornnarion contained in this report is true, accurate, aml in full compliance with legal requireutents. <br />Technician's Signature: r" '- 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 />