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CEIVED <br /> Gf III f d-RYAN INC. G JAN#2 2 20 16 <br /> 016 20-640046 <br /> SWRCB,January 2006 <br /> Spill Bucket Testing Report For ENVIRONMENTAL <br /> This form is intended �iEALTH DEPARTMENT <br /> f 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: Arco 2186 Date of Testing: 1/7/2016 <br /> Facility Address: 32.12 N California St.,Stockton <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing: 12/4/2015 <br /> ame o oca -Agency Inspector i present during testing): <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: Gettler-Ryan Inc.,6805 Sierra Court Suite G,Dublin,Ca.94568 Ph.#925-551-7555 <br /> Technician Conducting Test: Tim Adams <br /> Credentials:(1) CSL.B Contractor ICC service Tech. SWRCB Tank Tester Other(Specify) <br /> License Number: 220793 ICC Tech Number: 8205730 <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: Hydrostatic Vacuum Other <br /> Test Equipment Used: Standard Tape Measurer Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By Tank 1 87-1 Vapor 2 87-2 Vapor3 87-2 Vapor 4 91 Vapor <br /> Number,Stored Product, etc. <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 Sump <br /> Bucket Diameter: 12" 12" 12" 12" <br /> Bucket Depth: 14" 14" 14" 1.1" <br /> Wait time between applying <br /> Imin !min Imin Imin <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 11:00 11:00 11:00 11:00 <br /> Initial Reading(Ri): 13" 13" 13" 13" <br /> Test End Time(Tf): 12:00 12:00 12:00 12:00 <br /> Final Reading(Rf) 13" 13" 13" 13" <br /> Test duration(Tf-Ti): 1 hr I hr 1 hr I hr <br /> Change in Reading(URi): 0 0 0 0 <br /> Pass/Fail Threshold or Criteria: 0 0 0 0 <br /> Test Results: x Pass Fail x Pass Fail 1 x Pass Fail 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 Ike 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 />