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S WRCB,January 2006 <br /> Spill Bucket Testing Report Form <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('['applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Names: Arco AMPM Date of Testing: 5/16/2017 <br /> Facility Address: 4855 S HWY 99 Stockton Ca 95215 <br /> Facility Contact: Niema I Phone: 949-690-0546 <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: ELITE IV CONTRACTORS <br /> Technician Conducting Test: Mike K. <br /> Credentials: CSLB Contractor X ICC Service Tech. SWRCB Tank Tester Other(Specify) <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 Bucket(By 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(TO: <br /> Initial Reading(&): 13 %2" 13 %i' <br /> Test End Time(TF): 1Hr 1Hr <br /> Final Reading(RF): 13 %2" 13 <br /> Test Duration(TF—Tj): 1Hr 1Hr ENVIRO <br /> Change in Reading(RF-Rj): 0 0 <br /> PassfFail Threshold or <br /> Criteria: <br /> Test Result: X Pass D Fail X Pass D Fail X Pass ❑Fail ❑ Pass D Fail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up forfailed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the information contained in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: !. / Date: 5 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 />