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• • SWRCB,January 2006 <br /> 9. 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/operatorfor submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> FacilityName: ARCO # 09600, CC 18022603 1 Dateof Testing: 03/26/2008 <br /> Facility Address: 1250 N. WILSON WAY , STOCKTON, CA, 95205 <br /> Facility Contact: MANAGER Phone: (209) 465-5359 <br /> Date Local Agency Was Notified of Testing: 03/18/2008 <br /> Name of Local Agency Inspector(if present during testing): GARRETT BACKUS <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: JOEY MESA <br /> Credentialst: ❑CSLB Contractor X❑ICC Service Tech. ❑SWRCB Tank Tester E Other(Specify) ICC SERVICE <br /> License Number: 5259458-UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: K❑ Hydrostatic Vacuum D Other <br /> Test Equipment Used: TAPE MEASURE Equipment Resolution:VISUAL LOSS <br /> Identify Spill Bucket(By Tank r 1 AEG FILL = 2 MID FILL 3 3 SUP FILL i <br /> Number, Stored Product, etc.) <br /> ❑Direct Bury ❑ Direct Bury ❑Direct Bury ❑Direct Bury <br /> Bucket Installation Type: ❑ Contained in Sump 0 Contained in Sump Q Contained in Sump ❑Contained in Sump <br /> Bucket Diameter: 12-1 1211 121- <br /> Bucket <br /> 2"Bucket Depth: 15 1/2" 15 1/2" 15 1/21- <br /> Wait <br /> /2"Wait time between applying 5 MIN. 5 MIN. 5 MIN. <br /> vacuum/water and starting test: <br /> Test Start Time(TI ): 9:00 9:00 9:00 <br /> Initial Reading(RL ): 11" 12" 13" <br /> Test End Time(TF): 10:05 10:05 10:05 <br /> Final Reading(RF ): 11" 12" 13" <br /> Test Duration: 60 MIN. 60 MIN. 60 MIN. <br /> Change in Reading(R F-RI ): 0" 0" 0" <br /> Pass/Fail Threshold or VISUAL LOSS VISUAL LOSS VISUAL LOSS <br /> Criteria: <br /> Test Result: x❑Pass' Fail Pass Fail Pass D Fail 171 Pass ❑ Tail <br /> Comments - (include information on repairs made prior to testing, and recmnmended follow-up for failed 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: h/"" Date: 03/26/2008 <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 />