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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 (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACTI,TTV INFORMATION <br />Facility Name: ARP Mini Mart 76 Date of Testing: 03/21/2012 <br />Facility Address: 25775 So. Patterson Rd., Tracy, Ca. 95376 <br />Facility Contact: Neil Patel I Phone: (510) 299-1219 <br />Date Local Agency Was Notified of Testing: O —$Q-1 a <br />Name of Local Agency Inspector (f present during testing): Thuy Tran <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: Reliable Petroleum Services Inc. <br />Technician Conducting Test: Guadalupe Sanchez <br />Credentials': x CSLB Contractor x ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other (Spec) <br />License Number(s): 883706 5250451 -UT <br />3. SPILL RTICKF.T TESTING INFORMATION <br />Test Method Used: xHydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: Standard Tape Measure <br />Equipment Resolution: N/A <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc1.2 <br />1 T1: 87 Slave Fill <br />2 T2: 87 Master Fill <br />3 T3: 87 Syphon <br />Fill <br />4 T4: 91 Fill <br />Bucket Installation Type: <br />Direct Bury <br />x Contained in Sump <br />Direct Bury <br />x Contained in Sump <br />Direct Bury <br />x Contained in Sump <br />Direct Bury <br />x Contained in Sum <br />Bucket Diameter: <br />12" <br />12" <br />12" <br />12" <br />Bucket Depth: <br />131/2" <br />13" <br />131/4" <br />141/2" <br />Wait time between applying <br />vacuum/water and start of test: <br />1 minute <br />1 minute <br />1 minute <br />1 minute <br />Test Start Time (TI): <br />12:21 p.m. <br />12:22 p.m. <br />12:23 p.m. <br />12:24 p.m. <br />Initial Reading (RI): <br />123/4" <br />12 1/8" <br />12 5/8" <br />14" <br />Test End Time (TF): <br />1:21 p.m. <br />1:22 p.m. <br />1:23 p.m. <br />1:24 p.m. <br />Final Reading (RF): <br />12 V <br />12 1/8" <br />12 5/8" <br />.14" <br />Test Duration (TF — TI): <br />l hr <br />1 hr <br />1 hr <br />1 hr <br />Change in Reading (RF - Rj): <br />0 <br />0 <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />1/16" <br />1/16" <br />1/16" <br />1/16" <br />Test Result: <br />x Pass ❑ Fail <br />x Pass ❑ Fail <br />x Pass ❑ Fail <br />x Pass []Fail <br />Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />1 hereby certify that all the information contained in this report is true, accurate, and in full compliance with legal requirements. <br />Technician's Signator Date 03/21/2012 <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 />