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0 0 <br />Spill Bucket Testing Report Form <br />SWRCB, January 2006 <br />This form is intended for use liv contractors performing annual testing of UST spill containment structures. The completed form and <br />printouts from tests (if'app/icab/e), should he provided to the. facility owner/operator for submittal to the local regulatoty agency. <br />1. FACILITY INFORMATION <br />Facility Name <br />Arco_ I Date of Testing: 10/21/2015 <br />Facility Address: <br />2430 Joe Pombo Pkwy, Tracy, Ca. 95376 <br />Facility Contact: <br />Ranjeet I Phone: (209) 579-4014 <br />Date Local Agency <br />Was Notified of Testing: 10/09/2015 <br />Name of Local Agency Inspector (if present during testing): Aris Cacapit <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: Diamond Petroleum Services, Inc. <br />Technician Conducting Test: Guadalupe Sanchez <br />Credentials: x CSLB Contractor x ICC Service Tech. 'SW RCB Tank Tester Other (,Spec) <br />License Number(s): 1005444 5250451 -UT <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: <br />Vacuum <br />Other <br />_xHydrostatic <br />Test Equipment Used: Standard Tape Measure <br />Identify Spill Bucket (B), Tank 1 T1: 87 Master Fill <br />Number, Stored Product. etc.) West <br />2 T2: 87 Master Fill <br />East <br />Equipment Resolution: 1/16" <br />3 T3: 87 Siphon 4 T4: 91 Fill <br />Fill <br />Bucket Installation Type: <br />Direct Bury <br />x Contained in Sump <br />Direct Bury <br />x Contained in Sump <br />Direct Bury <br />x Contained in Sump <br />Direct Bury <br />Contained in Sum <br />Bucket Diameter: <br />12" <br />12" <br />12" <br />12" <br />Bucket Depth: <br />17" <br />17'/e" <br />16'/2" <br />16'/2" <br />Wait time between applying <br />vacuum/water and start of test: <br />1 minute <br />I minute <br />I minute <br />I minute <br />Test Start Time (T,): <br />928 a.m. <br />9:28 a.m. <br />9:28 a.m. <br />9:28 a.m. <br />Initial Reading(R,): <br />15" <br />15" <br />13 5/8" <br />141/2" <br />Test End Time (T,.): <br />10:28 a.m. <br />10:28 a.m. <br />10:28 a.m. <br />10:28 a.m. <br />Final Reading (RF): <br />15" <br />15" <br />13 5/8" <br />14'/a' <br />Test Duration (T,: — T,): <br />I hr <br />I hr <br />I hr <br />I hr <br />Change in Reading (R,: - R,): <br />(1 <br />0 <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />1/16" <br />1/16" <br />1/16" <br />1/16" <br />Test Result: <br />x Pass ❑ Fail <br />x Pass 0 Fail <br />x Pass ❑ Fail <br />x Pass Fail <br />Comments — (include information on repairs made prior to testing, and recomtnended follow -tip f it failed tests) <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING • m <br />/ /hereby certify that all the information contained in this report is true, accurate, and in full compliance with legal requirements. <br />Technician's Signature* .�.-_�_�'�F-_ Date 10/21/2015 <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 />