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SWRCB,January 2006 Spill Bucket Testing Report Form This form is intended for use by contractors performing annual testing of UST spill containment structures. The completed form and printouts from tests(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: Arco AmPm#2186 Date of Testing: 5/22/09 Facility Address: 3212 N.California St., Stockton Ca Facility Contact: Kevin Vo Phone: (209)941-2694 Date Local Agency Was Notified of Testing Name of Local Agency Inspector(ifpresent during testing): 2. TESTING CONTRACTOR INFORMATION Company Name: Gettler-Ryan Inc. Technician Conducting Test: Pete Garcia 5300833-UT Credentials': ❑CSLB Contractor X ICC Service Tech. ❑SWRCB Tank Tester ❑Other(Specify) License Number(s): 220793 3. SPILL BUCKET TESTING INFORMATION Test Method Used: ❑Hydrostatic Vacuum ❑Other Test Equipment Used: I Equipment Resolution: Identify Spill Bucket(By Tank 1 2 3 4 Number, Stored Product, etc.) 1-87 Master 2-89 Master 2-87 Siphon 3-91 Bucket Installation Type: ❑ Direct Bury Direct Bury ❑ Direct Bury ❑Direct Bury X Contained in Sump X Contained in Sump X Contained in Sump X Contained in Sum Bucket Diameter: 12" 12" 12" 12" Bucket Depth: 12" 12" 12" 12" Wait time between applying 15min l 5min 15min 15min vacuum/water and start of test: Test Start Time(Ti): 3:51 pm 3:51 pm 3:5 1 pm 3:51 pm Initial Reading(Rj): 11 5/8" 11 7/8" 11 3/8" 10 3/4" Test End Time(TF): 4:51 pm 4:51 pm 4:51 pm 4:51 pm Final Reading(RF): 11 5/8" 11 7/8" 11 3/8" 10 3/4" Test Duration(TF—Tj): I hr 1 hr I hr 1 hr Change in Reading(RF-Rj): 0 0 0 0 Pass/Fail Threshold or 0 0 0 0 Criteria: Test Result: X Pass []Fail X Pass ❑Fail X Pass ❑Fail X Pass ❑Fail Comments—(include information on repairs made prior to testing, and recommended follow-up for failed tests) All Fill Spill Tested Good. CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING I hereby certify that all the information contained in this report is true,accurate, and in full compliance with legal requirements. Technician's Signature: Date: ' State laws and regulations do not currently require testing to be performed by a qualified contractor. However,local requirements may be more stringent.