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♦ <br /> Spill C et 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 AM PM#82602 1 Date of Testing: 10/27/11 <br /> Facility Address:2430 Joe Pombo Parkway,Tracy CA 95377 <br /> Facility Contact: Ranjeet Singh Phone:209-830-8778 <br /> Date Local Agency Was Notified of Testing: 10/19/11 <br /> Name of Local Agency Inspector(tf present during testing): Thuy Tran <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:Reliable Petroleum Services Inc. <br /> Technician Conducting Test:Guadalupe Sanchez <br /> Credentials': X CSLB Contractor X ICC Service Tech. ❑SWRCB Tank Tester ❑Other(Spec) <br /> License Number(s):883706 5250451-UT <br /> s <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: X Hydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used:Standard T ape Measure Equipment Resolution: <br /> Identify Spill Bucket(By Tank Tl: 87 Master West T2: 87 Slave Fill T3: 91 Fill T1: 87 Master East <br /> Number, Stored Product, etc.) Fill Fill <br /> Bucket Installation Type: Direct Bury Direct Bury Direct Bury Direct Bury <br /> X Contained in Sump X Contained in Sum X Contained in Sum X Contained in Sum <br /> Bucket Diameter: 12" 12" 12" 12" <br /> Bucket Depth: 15 3/8" 14%:" 151/4" 171/2" <br /> Wait time between applying 1 min. 1 min. 1 min. 1 min. <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 11:40a.m 11:35a.m 11:35a.m 11:40a.m <br /> Initial Reading(RI): 14 1/8" 14 7/8" 14 7/8" 15 3/8" <br /> Test End Time(TF): 12:40p.m 12:35p.m 12:35p.m 12:40p.m <br /> Final Reading(RF): 141/8" 14 7/8" 14 7/8" 15 3/8" <br /> Test Duration(TF—Tj): 1 Hour 1 Hour 1 Hour 1 Hour <br /> Change in Reading(RF-RI): 0 0 0 0 <br /> Pass/Fail Threshold or 1/16" 1/16" 1/16" 1/16" <br /> Criteria: <br /> Test-Result X Psszi1 ,kas 3 earl; ♦' X Pass,- D Fail X bass , ❑Fail <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 /> I hereby certify that all the information contained in this report is true,accurate,and in full compliance with legal requirements. <br /> �, f <br /> Technician's Signature: " ' Date:10/27/11 <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 />