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6wize-RYAN INC. <br />GR Job # 1720-4947 <br />SWRCB, 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 rif applicable), should be provided to the facility owneNoperator for submittal to the local regulatory agency. <br />1 CA!`11 rTV iwlCnnwl�mrw <br />I TpQTR Vin VI -O A r`Tno rwrcr.nw,.. mrw <br />Company Name: Gettler-Ryan Inc., 6805 Sierra Court, Suite G, Dublin, Ca. 94568 -Ph.k 925-551-7555 <br />Technician Conducting Test: Alexander Tate <br />Credentials: (1) CSLB Contractor ICC serviceTech. SWRCB Tank Tester Other (Specify) <br />License Number: 220793 ICC Tech Number: <br />i 4;p11.1, R1101CFT TRQTrN!` rncnow,r T. , <br />Test Method Used: <br />Hydrostatic <br />26 20: is <br />Other <br />1400 E. Victor Rd <br />Lodi 95240 <br />EN�:12 <br />Dar 1 Lee <br />Phone: 415-902-5089 <br />cy Was Notified of Testing: <br />IdentifySpill Bucket (By Tank <br />Stored Product, ete.l <br />gency nspector i present wring iestin . <br />2 <br />I TpQTR Vin VI -O A r`Tno rwrcr.nw,.. mrw <br />Company Name: Gettler-Ryan Inc., 6805 Sierra Court, Suite G, Dublin, Ca. 94568 -Ph.k 925-551-7555 <br />Technician Conducting Test: Alexander Tate <br />Credentials: (1) CSLB Contractor ICC serviceTech. SWRCB Tank Tester Other (Specify) <br />License Number: 220793 ICC Tech Number: <br />i 4;p11.1, R1101CFT TRQTrN!` rncnow,r T. , <br />Test Method Used: <br />Hydrostatic <br />Vacuum <br />Other <br />Test Equipment Used: <br />Standard Tape Measurer <br />Equipment Resolution: 1/16" <br />IdentifySpill Bucket (By Tank <br />Stored Product, ete.l <br />1 DSL <br />2 <br />3 4 <br />'type: <br />Direct Bury <br />Contained in Sump <br />rrec[Bury <br />DContained in Sump <br />Mired Bury irec[ wry <br />[]Contained in Sump Contained in Sump <br />iameter: <br />ETime <br />13 <br />epth: <br />11 <br />e between applying <br />water and start of test: <br />5 mins <br />Time (Ti): <br />10 • 10 <br />•1 <br />Initial Reading (Ri): <br />10 4 <br />Test End Time (Tl): <br />11: 10 <br />Final Reading (RI) <br />10 1/4 <br />Test duration (Tf- Ti): <br />1 Hr <br />Change in Reading (Rf-Ri): <br />0 <br />Pass/Fail Threshold or Criteria: <br />0 <br />0 <br />U p <br />Test esa ts: <br />+ ass ailElPass <br />FIFO <br />—ff_Pau FailPass Fail <br />uumumuu - tmcivae mJormarion on repairs maae prior to testing, and <br />Fill Spill Bucket;OPE <br />CERTIFICATION <br />i nereoy, cernly that art the information contained in this report is true, accurate, and in full compliance with legal requirements <br />Technician's Signature: Z Date: 1/26/2017 <br />(I) 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 />