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®Gfrufff-RYAN INC. . �RJob# 20-572367 <br /> 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 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.FACILITY INFORMATION <br /> Facility Name: PG&E Stockton Service Center Date of Testing: 9/27/2011 <br /> Facility Address: 4040 West Lane,Stockton <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing: 8/5/2011 <br /> Name of LocaTTgcucyTn_sp_e_ctor i present tiring testing) <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: Gettler-Ryan Inc.,6747 Sierra Court Suite J,Dublin,Co.94568 Ph.#925-551-7555 <br /> Technician Conducting Test: Chris San Nicolas <br /> Credentials:(1) CSLB Contractor ICC service Tech S W RCB Tank Tester Other(Specify) <br /> License Number: 220793 ICC Tech Number: 5296364-UT <br /> 3.SPELL BUCKET TESTING INFORMATION <br /> Test Method Used: Hydrostatic Vacuum Other <br /> Test Equipment Used: Standard Tape Measurer Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By Tank 1 Unleaded 2 Diesel 3 WastPOil 4 <br /> Number,Stored Product, etc. <br /> Bucket Installation Type: it Direct Bury x Direct Bury x Direct Bury Direct Bury <br /> Contained in Sump Contained in Sump Contained in Sump Contained in Sump <br /> Bucket Diameter: 12" 12" 12" <br /> Bucket Depth: 13 1/2" 13" 14" <br /> Wait time between applying <br /> vacuum/water and start of test: 10 min. ]0 min. 10 min. <br /> Test Start Time(Ti): 10:00 10:30 10:00 <br /> Initial Reading(Ri): 12.5" 11" 12" <br /> Test End Time(Tf): 11:00 11:30 11:00 <br /> Final Reading(Rf) 12 1/2" 12" 12" <br /> Test duration(Tf-Ti): 60 min. 60 min. 60 min. <br /> Change in Reading(Rf-Ri): 0 0 0 <br /> Pass/Fail Threshold or Criteria: 0 0 0 0 <br /> Test Results: Pass Fail UU Fall Pass Fall Pus Fail <br /> Comments-(include information on repairs made prior to testing,and recommended follow-up for jailed tests) <br /> CERTFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the information contained In this report Is hue,accurate,and in full compliance with legal requirements <br /> Technician's Signature: C' � Date: 9/27/2011 <br /> (1) 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 />