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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_ FAC'ii.ITV INFORMATION <br />Facility Name: ARP Mini Mart 76 Date of Testing: 4/07/2011 <br />Facility Address: 25775 S. Patterson Pass Rd. <br />Facility Contact: Niel Patel Phone: 510-299-1219 <br />Date Local Agency Was Notified of Testing: March 30", 2011 <br />Name of Local Agency Inspector (if present during testing): Thuy Tran <br />2_ TFNTINC.' C'.nNTRAC'.TOR INFORMATinN <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 BUCKET TESTING INFORMATION <br />Test Method Used: X Hydrostatic _ Vacuum U Other <br />Test Equipment Used: Standard Tape Measure <br />Equipment Resolution: N/A <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />T-1 Blue SlaveFill <br />Bucket <br />T-2 Blue Master Fill <br />Bucket <br />T -3 Blue Syphon <br />Fill Bucket <br />T-4 91 Fill Bucket <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 />14" <br />13 1/2" <br />13 '/2" <br />14 '/" <br />Wait time between applying <br />vacuum/water and start of test: <br />I min. <br />1 min. <br />1 min. <br />I min. <br />Test Start Time (Tj): <br />11:30 am <br />11:30 am <br />11:31 am <br />11:31 am <br />Initial Reading (Rj): <br />.12''/4" <br />11 '/o" <br />11 3/4" <br />13" <br />Test End Time (TF): <br />12;30 pm <br />12:30 pm <br />12:31 pm <br />12:31 pm <br />Final Reading (RF): <br />12 '/4" <br />11 'A <br />11 %11 <br />13" <br />Test Duration (TF — Tj): <br />1 Hour <br />I Hour <br />1 Hour <br />1 Hour <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 0 Fail <br />CommentS — (include information on repairs made prior to testing, and recommended follo",-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: <br />Date: April 7, 2011 <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 />