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MAY ����10 January 2006 <br /> Spill Bucket Testing Report Form V <br /> This form is intended for use by contractors performing annual testing of UST spill containment slydures—TJx-,cot pleted foam and <br /> printouts from tests(if applicable),should be provided to the facility owner/operator for submittallo the locb(regtrlatory agency. <br /> 1. FACILITY INFORMAT_ION <br /> Facility Name: ARP Mini Mart 76 Date of Testino: 4/11/2016 <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: 3/29/2016 <br /> Name of Local Agency Inspector(rfpresent during testing): Vicki McCartney <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Diamond Petroleum Services, inc. <br /> Technician Conducting Test: Guadalupe Sanchez <br /> Credentials': x CSLB Contractor x ICC Service Tech. 0 SWRCB Tank"rester 0 Other(Spec) <br /> License Number(s): 1005444 5250451-UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: xHydrostatic Vacuum 0 Other <br /> Test Equipment Used: Standard Tape Measure Equipment Resolution: 1/I6" <br /> Identify Spill Bucket(lay Tank 1 T1: 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: 13 3/4" 12'/4" 13 ''/s" 13 '/4" <br /> Wait time between applying I minute i minute 1 minute 1 minute <br /> vacuum/water and start of test: <br /> Test Start Time(Tt): 11:08 a.m. 11:08 a.m. 11:07 a.m. 11:07 a.m. <br /> Initial Reading(Rt): 13" 115/8" 13" 12 7/8" <br /> Test End Time(TF): 11:12 a.m. 12:08 p.m. 1 1:12 p.m. 12:07 p.m. <br /> Final Reading(RF): 12" 115/8" 12" 12 7/8" <br /> Test Duration(TF—Tt): 4 minutes lhr 5 minutes I hr <br /> Change in Reading(RF-Ri): 1" 0 1" 0 <br /> Pass/Fail Threshold or I 1/16" 1/16" <br /> Criteria: <br /> Test Result: Pass x Fail x Pass 0 Fail Pass x Fail x Pass ❑ Fail <br /> Comments—(include u>a•mation ou repairs made prior to testing, and recommended follow•-:rp for failed tests) <br /> Spill Buckets on 87 Slave Fill and 87 Siphon Fill need to be replaced <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby cert that all the information contained in this report is true,accurate,and in fill compliance with legal requirements. <br /> Technician's Signature: a '^ Date 4/11/2016 <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 />