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S W RCB. January 2006 <br /> Spill Bucket 'Testing Report Form <br /> This form is intended for use by contractors performing annual testing of UST spill conturvurtent structures. The completed form and <br /> printouts from tests(if applicable), should be provided to the faciliij,ownerJoperator fi r.%ubmutal to the local regulator"agency. <br /> 1. FACILITY INFORMATION <br /> Facilitv Name: Arco I Date of Twin-: 10/24/2017 <br /> Facility Address: 1340 Colony Rd, Ripon, Ca.95366 <br /> Facility Contact: Ranjeet Phone: (2Q9)579-4014 <br /> Date Local Agency Was Notified of Testing: 10/9/2017 <br /> Name of Local Agency Inspector(ifpresent during testing): Elianna Florido and JohniAlth- <br /> 2. TESTING CONTRACTOR INFORMATION NOV 2 1 2017 <br /> Company Name: Diamond Petroleum Services. Inc. <br /> Technician Conducting Test: Guadalupe Sanchez TH <br /> Credentials': x CSLB Contractor x ICC Service Tech. I I SWRCB Tank Tester L Other(.peC7Vi) <br /> License Number(s): 1005444 5250451 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: xHydrostatic D Vacuum Other <br /> Test Equipment Used: Standard Tape Measure Equipment Resolution: 1/16" <br /> Identify Spill Bucket (fat- 7'Unk 1 T1: 87 Fill West 2 TI:87 Fill East 3 T2: 91 Fill 4 T3: Diesel Fill <br /> Number, Stored Product, etc.) <br /> Bucket Installation Type: Direct Bury Direct Bury Direct Bury Direct Bury <br /> x Contained in Sump x Contained in Sump x Contained in Sump Contained in Sum <br /> Bucket Diameter: 12" 12" 12" 12" <br /> Bucket Depth: 15" i 13 '/z" 14`/Z' 15" <br /> Wait time between applyin, I minute 1 minute 1 minute 1 minute <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 3:13 p.m. 2:55 p.m. 2:26 p.m. 2:59 p.m. <br /> Initial Reading(Rj): 13 ! 12 7/8" 13 5/8" 13 5/8" <br /> Test End Time(TF): 4:13 p.m. 3:55 p.m. 3:26 p.m. 3:59 p.m. <br /> Final Reading(RF): 13 %z" 12 7/8" 13 5/8" 13 5/8" <br /> Test Duration(TF-Ti): 1 hr I hr 1 hr I hr <br /> Change in Reading(RF-Rt): 0 0 0 0 <br /> Pass/Fail Threshold or 1/16" 1/16" 1/16" I/16" <br /> Criteria: <br /> Test Result: x Pass 0 Fail x Pass D Fail x Pass 0 Fail x Pass 0 Fail <br /> -Comments—(include information on repairs made prior to tG titins, and recornmended follow-itp for failed tests) <br /> Replaced spill bucket O-ring in the 87 fill gest Inspector on site <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> hereby certify'Iltat all the information contained in tlds report is true,accurate,and in full complianee with legal requirements. <br /> Technician's Signature: F ei�.e J/r Date: 10/24/2017 <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 />