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FA GErna-RYAN 1Nc. 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 ownerloperator for submittal to the local regulatory agency. <br />"11 YITR°I If 16191`7 03-1110 E11 tam <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 />ame o oca gencynspector i present during testing : Stacy Rivera <br />I Q 1'► VC / ► 1 u 1 <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 (Specify) <br />License Number: 220793 ICC Tech Number: 5296364 -UT 11 <br />3. SPELL BUCKET TESTING INFORMATION <br />Test Method Used: Hydrostatic Vacuum Other <br />Test Equipment Used: Standard Tape Measurer Equipment Resolution: 1/16" <br />Identify Spill Bucket (By Tank 1 87 Master Fill 2 87 Siphon Fill 3 91 Fill 4 <br />Number, Stored Product, etc) <br />Bucket Installation Type: <br />Direct Bury <br />Contained in Sump <br />Direct Bury Direct Bury Direct Bury <br />X Contained in Sump X Contained in Sump Contained in Sump <br />Bucket Diameter: <br />1241 <br />1244 12" <br />Bucket Depth: <br />1511 <br />1380 1611 <br />Wait time between applying <br />vacuum/water and start of test: <br />lOmin <br />lOmin lOmin <br />Test Start Time (Ti): <br />12:30 <br />1:45 12:30 <br />Initial Reading (Ri): <br />14.511 <br />12 7/8" 151/411 <br />Test End Time (Tf): <br />1:30 <br />2:45 1:30 <br />Final Reading (Rf) <br />14.5" <br />12 7/8" 151/411 <br />Test duration (Tf - Ti): <br />lhr <br />lhr Ihr <br />Change in Reading (Rf-Ri): <br />0 <br />0 0 <br />Pass/Fail Threshold or Criteria: <br />0 <br />0 0 <br />Test Results: <br />X , Pass ' Fail <br />X Pass Fail X 'Pan Fail 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 />