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imtiETTEER-RYAN INC. G& Job # <br />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 (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />Facility Name: Arco 5450 Date of Testing: 8/5/2014 <br />Facility Address: 1617 W Fremont Stockton, CA <br />Facility Contact: Phone: <br />Date Local Agency Was Notified of Testing: <br />,lRame of Localgency Inspector i present during testin Stacy Rivera <br />P46 9 *110 1 010KIKI vt I i 1 a /, <br />Company Name: Gettler-Ryan Inc., 6805 Sierra Court Suite G, Dublin, Ca. 94568 Ph.# 925-551-7555 <br />Technician Conducting Test: Chris San Nicolas <br />Credentials: (1) CSLB Contractor ICC service Tech. SWRCB Tank Tester Other (Spec) <br />License Number: 220793 ICC Tech Number: 5296364 -UT <br />Test Method Used: <br />Hydrostatic <br />Vacuum <br />Other <br />Test Equipment Used: <br />Standard Tape Measurer <br />Equipment Resolution: 1/16" <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc. <br />1 87 Master Vapor <br />2 87 Siphon Vapor <br />3 91 Vapor 4 <br />Bucket Installation Type: <br />Direct Bury <br />Contained in Sump <br />Direct Bury <br />X Contained in Sump <br />Direct Bury Direct Bury <br />X Contained in Sump Contained in Sump <br />Bucket Diameter: <br />12" <br />12°° <br />12" <br />Bucket Depth: <br />Wait time between applying <br />vacuum/water and start of test: <br />14.5" <br />10min <br />15" <br />10min <br />15" <br />10min <br />Test Start Time (Ti): <br />1:50 <br />2:50 <br />1:50 <br />Initial Reading (Ri): <br />12 3/4" <br />13" <br />14" <br />Test End Time (Tf): <br />2:50 <br />3:50 <br />2:50 <br />Final Reading (Rf) <br />123/411 <br />13" <br />1401 <br />Test duration (Tf - Ti): <br />lhr <br />lhr <br />lhr <br />Change in Reading (Tf-Ri): <br />0 <br />0 <br />0 <br />Pass/Fail Threshold or Criteria: <br />0 <br />0 <br />0 <br />1 <br />i X Pass Fail" <br />X Pass-' Fag <br />X Pass Fag Pass "Fail <br />Comments - (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />CERTFICATION 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: <br />Date: 8/5/2014 <br />(1) 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 />