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SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intended for use by contractors performing annual testing of UST spill containment structures. The completed form and <br /> printouts from tests (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Arco BP 5450 1 Date of Testing: 9/l/11 <br /> Facility Address: 1617 W.Fremont, Stockton,CA 95203 <br /> Facility Contact: Not Reported Phone: 209-462-1617 <br /> Date Local Agency Was Notified of Testing: 8/9/11 <br /> Name of Local Agency Inspector(rfpresent during testing): Stacy Rivera <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Fueling&Service Technologies,Inc.(FASTECH) <br /> Technician Conducting Test: Omar Ruiz ICC#5264160-UT <br /> Credentials': X CSLB Contractor X ICC Service Tech. ❑SWRCB Tank Tester ❑Other(Spec) <br /> License Number(s): Type-A,HAZ,C21; No. 794519 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ❑ Hydrostatic ❑ Vacuum X Other-Visual <br /> Test Equipment Used: tape measure Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1 91 fill 2 91vapor 3 87 fill aux(retest) e . <br /> (retest) <br /> Number, Stored Product, etc.) <br /> Bucket Installation Type: ❑Direct Bury ❑ Direct Bury ❑ Direct Bury ❑ Direct Bury <br /> ®Contained in Sump ® Contained in Sump ® Contained in Sump ® Contained in Sum <br /> Bucket Diameter: 12" 12" 12" 12" <br /> Bucket Depth: 16" 16" 16" 16" <br /> Wait time between applying 15 min 15 min 15 min 15 min <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 11:45am 11:45am 2pm 2pm <br /> Initial Reading(Rj): 15" 15" 15" 15" <br /> Test End Time(TF): 12:45pm 12:45pm 3pm 3pm <br /> ii Final Reading(RF): 14.25" 15" 15" 15" <br /> Test Duration(TF—Tj): 1 hour l hour l hour 1 hour <br /> Change in Reading(RF-Rj): 0.75 0.00 0.00 0.00 <br /> Pass/Fail Threshold or 0.00 0.00 0.00 0.00 <br /> Criteria: <br /> Test Result: ❑ Pass 0 Fail E Pass ❑Fail ® Pass ❑Fail ® Pass ❑Fail <br /> Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> 87 aux and 91 fills failed initial testing... drain valves were full of debris...cleaned out and retested...passed <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <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: Date: 9/1/11 <br /> State laws and regulations do not currently require testing to be performed by a qualified contractor.However, local requirements <br /> may be more stringent. <br />