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FWCEIVE® <br /> ®61Erria-Ryn INC. 2 2 20 6 20-640046 <br /> T ENVIRONMEN1R11,January 2006 L <br /> Spill Bucket Testing Report ForInHEALTH DEPARTMENT <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 /> aci ttyName: Arco 2186 Date of Testing: 1/7/2016 <br /> Facility Address: 3212 N California St.,Stockton <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing: 12/4/2015 <br /> ,jNamc or Local Agency inspcMor(ypresent uri testing-): <br /> 2.TESTING CONTRACTOR INFORMATION <br /> CompanyName: etter- yan Inc..6805 Sierra Court Suite G,Dublin,Ca.94568 Ph.N925-551-7555 <br /> Technician Conducting Test: Tim Adams <br /> Credentials:(1) CSLB Contractor ICC service Tech. SWRCB Tank Tester Other(peci ) <br /> License Number: 220793 ICC TechNumber: 8205730 <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: rostattc Vacuum OtEer <br /> Test Equipment Used: Standard Tape Measurer Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By Tank 1 87-1 Fill 2 87-2 Fill 3 87-2 Fill 4 91 Fill <br /> Number,Stored Product,etc. <br /> Bucket Installation Type: Direct Bury Direct Bury Direct Bury Direct Bury <br /> t Contained in Sump x Contained in Sump x Contained in Sump x Contained in Sump <br /> Bucket Diameter: 12" 12" 12" 12" <br /> Bucket Depth: 14" 14" 14" 14" <br /> Wait time between applying <br /> vacuum/water and start of test: 1 min 1 min 1 min I min <br /> Test Start Time(Ti): 10:30 10:30 10:30 10:30 <br /> Initial Reading(Ri): 10 3/4" 10 3/4" 10 3/4" 10 3/4" <br /> Test End Time(Tf): 11:30 11:30 11:30 11:30 <br /> Final Reading(Rf) 10 3/4" 103/41, 10 3/lFail <br /> 10 3/4" <br /> Test duration(Tf-Ti): 1 hr 1 hr 1 hr1 hr <br /> Changc in Reading(Rf-Ri): 0 0 0 0 <br /> Pass/Fail Threshold or Criteria: 0 0 0 0 <br /> Tat Results: x Pass Fail x Paas Fail x Pus x Pass Fail <br /> Comments-(include information on repairs made prior to testing,and recommended follow-up for failed tests) <br /> CERTFICATION 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: s Date: 1/7/2016 <br /> (1) 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 />