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HE(1j !-` VtU <br /> Wr <br /> SWRCB,January 2006 <br /> ENVIRONMENTAL HEALTH Spill Bucket Testing Report Form <br /> 77@RJor use by contractors performing annual testing of UST spill containment structures. The completed form and <br /> printouts from tests(ifapplicable),should be provided to thefocility owner/operatorfor submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Names: Arco AMPM I Date of Testing: 5/16/2017 <br /> Facility Address: 4855 S HWY 99 Stockton Ca 95215 <br /> Facility Contact: Niema Phone: 949-690-0546 <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: ELITE IV CONTRACTORS <br /> Technician Conducting Test: Joe B. <br /> Credentialst: CSLB Contractor X ICC Service Tech. S WRCB Tank Tester Other(Spec) 'V <br /> License Number(s): <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: X Hydrostatic Vacuum Other <br /> Test Equipment Used: Equipment Resolution: <br /> Identify Spill='B'y Tank 1 91 2 89 3 4 <br /> Number,Stored Product, etc. <br /> Bucket Installation Type: X Direct Bury X Direct Bury X Direct Bury Direct Bury <br /> Contained in Sump Contained in Sump Contained in Sump Contained in Sum <br /> Bucket Diameter: 12" 12" <br /> Bucket Depth: 14" 14" <br /> Wait time between applying 0 0 <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): <br /> Initial Reading(RO: 13 'h" 13 V2" <br /> Test End Time(TF): 1Hr 1Hr <br /> Final Reading(RF): 13%2" 13 %" <br /> Test Duration(TF—Tj): 1Hr 1Hr <br /> Change in Reading(RF-Rj): 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: X Pass 0 Fail X Pass 0 Fail X Pass 0 Fail 0 Pass 0 Fail <br /> Comments—(include irsformation 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 informaho ontained in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: (/ Date: IP I I <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 />