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A <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(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: ARP Mini Mart 76 1 Date of Testing: 03/28/2014 <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: 013-19-14r�n`-'VED <br /> Name of Local Agency Inspector(rf present during testing): Thuy Tran <br /> 2. TESTING CONTRACTOR INFORMATION APR <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(Speci EIVT <br /> LicenseNumber(s): 883706 5250451-UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: xHydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used: Standard Tape Measure Equipment Resolution:N/A <br /> Identify Spill Bucket(By Tank 1 Tl: 87 Slave Fill 2 T2: 87 Master Fill 3 T3: 87 Siphon 4 T4: 91 Fill <br /> Number, Stored Product, etc. Fill <br /> Bucket Installation Type: Direct Bury Direct Bury Direct Bury Direct Bury <br /> x Contained in Sump x Contained in Sump x Contained in Sump x Contained in Sum <br /> Bucket Diameter: 12" 12" 12" 12" <br /> Bucket Depth: 14" 13 ''/z" 13 3/4" 13 3/a" <br /> Wait time between applying I minute 1 minute 1 minute 1 minute <br /> vacuum/water and start of test: <br /> Test Start Time(Tj): 11:46 a.m. 11:46 a.m. 11:46 a.m. 11:46 a.m. <br /> Initial Reading(Rj): 12 3/4" 12" 12 3/8" 12 3/8" <br /> Test End Time(TF): 12:46 p.m. 12:46 p.m. 12:46 p.m. 12:46 p.m. <br /> Final Reading(RF): 12 3/4" 12" 12 3/8" 12 3/8" <br /> Test Duration(TF—TI): 1 hr 1 hr I hr I hr <br /> Change in Reading(RF-R,): 0 0 0 0 <br /> Pass/Fail Threshold or 1/16" 1/16" 1/16" 1/16" <br /> Criteria: <br /> Test Result: x Pass ❑ Fail x Pass ❑ Fail x Pass ❑ Fail 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 /> I hereby certify that all the information contained in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signa . �, 4: +e Date 03/28/2014 <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 />