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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 f om tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatwl> agency. <br />1. FACILITY INFORMATION <br />Facility Name: ARP Mini Mart Mobil Date of Testin,,: 318/2018 <br />Facility Address: 25775 So. Patterson Rd., Tracy, CA 95376 <br />Facility Contact: Neil Patel Phone: (5..,,, 'r�p <br />i i i P; <br />n- <br />Date Local Agency Was Notified of Testing: 2/28/2018 <br />1 T1: 87 Slave Fill <br />j <br />Name of Local Agency Inspector (tfpreseni during testing): Betty Ho 119 mg <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: Diamond Petroleum Services, inc. MITP"'` <br />MMIlAr <br />Technician Conducting Test: Guadalupe Sanchez <br />Credentials': x CSLB Contractor x ICC Service Tech. SWRCB Tank Tester � Other (Specify) <br />License Number(s): 1005444 5250451 <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: xHydrostatic Vacuum . Other <br />Test Equipment Used: Standard Tape Measure <br />Equipment Resolution: 1/16" <br />Identity Spill Bucket (By Tank <br />Number, Stored Product. etc.) <br />1 T1: 87 Slave Fill <br />2 T2: 87 Master Fill <br />3 T3: 87 Siphon <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 />17" <br />13 '!," <br />16 '/4" <br />13 '/4" <br />Wait time between applying <br />vacuum/water and start of test: <br />i minute <br />I minute <br />1 minute <br />1 minute <br />Test Start Time (Ti): <br />10:52 a.m. <br />10:53 a.m. <br />10:53 a.m. <br />10:50 a.m. <br />initial Reading (111): <br />16 5/8" <br />12 7/8" <br />16" <br />12 3/," <br />Test End Time (TF): <br />11:52 a.m. <br />11:53 a.m. <br />11:53 a.m. <br />11:50 a.m. <br />Final Reading (RF): <br />16 5/8" <br />12 7/8" <br />16" <br />12 3/<" <br />Test Duration (TF — Ti): <br />1 hr <br />i hr <br />I hr <br />1 hr <br />Change in Reading (RF- Ri): <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 h1lbrmation on repairs made prior to testing, and reconnnendedJolloi+,-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 wink lel; a/ requirements. <br />Technician's Signatu=— _ Date: 3/8/2018 <br />' State laws and regulations do not currently require testing to be perfonned by a qualified contractor. However, local requirements <br />may be more stringent. <br />