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SWRCB, January 2006 <br />This form is intended for use by contractors pedbrining annual testing of UST spill containment structures. The completed form and <br />printouts from tests (if applicable), should be provided to the facility omwerloperator.for, submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: Arco I Date of Testing: 6/14/2017 <br />Facility Address: 2430 Joe Pombo Pkwy, Tracy, Ca. 95376 <br />Facility Contact: Ranjeet Phone: (209) 579-4014 <br />Date Local Agency Was Notified of Testing <br />Name of Local Agencv Inspector fifnresent during testing): <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: xHydrostatic Vacuum Other <br />Test Equipment Used: Standard Tape Measure <br />Equipment Resolution: 1/16" <br />Identify Spill Bucket (By Tank I T2: 87 Siphon Fill <br />Number, Stored Product, etc.) <br />Bucket Installation Type: Direct Bury <br />x Contained in Sump <br />7 2 <br />Direct Bury <br />x Contained in Sump <br />3 <br />Direct Bury <br />x Contained in Sump <br />Direct Bury <br />Contained in Sump <br />Bucket Diameter: 12" <br />Bucket Depth: 15 1/2" <br />Wait time between applyingI minute <br />and start of test: <br />I a Boma <br />-vacuum/water <br />Test Start Time (Ti): 6:15 p.m. <br />Till <br />1 5 7017 <br />Initial Reading (R,): 11 'All <br />Test End Time (TF): 7:15 p.m. <br />E N VI R0 <br />N -1 A L H E A LT H <br />Final Reading (RF): 11 '/4 <br />DEPARTMENT <br />Test Duration (TF - Ti): I hr <br />Reading - Rj): 0 <br />Change in (RF <br />Pass/Fail Threshold or 1/16„ <br />Criteria: <br />Test Result: x Pass I <br />Pass 0 Fail <br />Pass 0 Fail <br />Pass <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 />/hereby certif <br />v that all the information contained In this report is true, accurate, and in full compliance with legal requirements. <br />Technician's Signature;,,.--�'__.r- — Date : 6/14/2017 <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 />