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Spill Bucket Testing Report Form SWRCB,January 2006 <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 owner/operator for submittal to the local regulatory agency. <br /> 1. FACILrI'Y INFORMATION <br /> Facility Name: ARCO I Date of Testing: 11/25/2014 <br /> Facility Address: 4855 S.State Route 9,Stockton,Ca.95215 <br /> Facility Contact: Gill Phone: (209)481-7445 <br /> Date Local Agency Was Notified of Testing: _) ?,-I y <br /> Name of Local Agency Inspector(ifpresent during testing): Jeff Wong <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 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: xHydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used: Standard Tape Measure Equipment Resolution: N/A <br /> Identify Spill Bucket(By Tank I TI:87 Fill SE 2 Tl: 87 Fill NE 3 T2: 89 Fill 4 T3: 91 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 Sumv x Contained in Sum <br /> Bucket Diameter: 12" 12" 12" 12" <br /> Bucket Depth: 13 '/s" 13 '/z" 13%" 13 3/." <br /> Wait time between applying <br /> vacuum/water and start of test: 1 minute I minute I minute 1 minute <br /> Test Start Time(T): 2:40 p.m. 2:40 p.m. 2:40 p.m. 2:40 p.m. <br /> Initial Reading(R,): 111/8" 111/8" 113/8" 115/8" <br /> Test End Time(TF): 3:40 p.m. 3:40 p.m. 3:40 p.m. 3:40 p.m. <br /> Final Reading(RF): 11 1/8" 11 1/8" 113/8" 11 5/8" <br /> Test Duration(TF—T,): 1 hr 1 hr 1 hr 1 hr <br /> Change in Reading(RF-R,): 0 0 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: 1/16" 1/16" 1/16" 1116" <br /> Test Result: x Pass ❑Fail x Pass ❑Fail x Pass 0 Fail x Pass 0 Fail <br /> Comments— include information on repairs made prior to testing, and recommended follow-u or ailed tests) <br /> ,. n <br /> 1 , u :l; _;7_,,L9NV1R0Nj.vjtNTAHEALTH <br /> CERTIFICATION OF TECHNICpkPj . , PgSIj3LE FOR CONDUCTING 1&EFMTPXL0NTT <br /> I hereby cert6 that all the information contained in this report Is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature/' � Date 11/25/2014 <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 />