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SWRCB, January 2000 <br />Spill Bucket Testing Report Form <br />This form is intendedfor use by contractors performing annual testing of UST spill containment structures. The completed form and printouts from tests (f <br />applicable), should be provided to the facility owner/operatorfor submittal to the local regulalwy agency. <br />i. FACILITV INFORMATION <br />Facility Name: Arco 5450 <br />Date ofTesting: 9/23/2010 <br />Facility Address: Street: 1617 W. Fremont St. <br />CITY: Stockton California <br />Facility Contact: Kelly <br />Phone: 209) 462-1617 <br />Date Local Agency Was Notified of Testing 911412010 <br />Visual Tape reading <br />Name of Local Agency Inspector i resent dur•in tesltn : <br />Ray Von Flue <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: Wayne Perry <br />Identify Spill Bucket (By Tank <br />Number, Stored Product etc.) <br />Technician Conductin Test: Brandon Smith <br />Credentials: 0 CSLB Contractor 0 ICC Service Tech. ❑ <br />SWRCB Tank Tester <br />License Number(s): 300345 <br />0 Other (Specify) <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: <br />° Hydrostatic <br />Vacuum <br />❑ Other S eci 9 <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 />87 Aux <br />91 <br />Fill ❑ Vapor <br />Fill ❑ Vapor 0 Fill ❑ Vapor <br />❑ Fill ❑ Vapor <br />Bucket Installation Type: <br />❑ Direct Bury <br />Direct Bury <br />❑ Direct Bury <br />Direct Bury <br />Contained in Sump <br />Contained in Sump <br />1±1 Contained in Sump <br />Contained in Sum <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 (Tr): <br />12:00 <br />12:00 <br />12:00 <br />Initial Reading (N): Inches <br />9.5 <br />9.5 <br />9.5 <br />Test End Time (TF): <br />13:00 <br />13:00 <br />13:00 <br />Final Reading (RF): Inches <br />9.5 <br />9.5 <br />9.5 <br />Test Duration (TF —Tr): <br />1 HOUR <br />1 HOUR <br />i HOUR <br />Change in Reading (RF-Rr): <br />0 <br />0 <br />0 <br />Pass/Fail Threshold or Criteria: <br />0 <br />0 <br />0 <br />Tut Result: <br />[] Pass LJ Fail <br />Pass Fail <br />R1 Pass Fail <br />❑ Pass El Fill <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 />7lrereby certify that all the information contained in this report is true, accurate, and in fill compliance with legal requlrenrents. <br />_ r— <br />Technician's Signature: r Date: 9/2312010 <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 />