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®GETTiEB-RYAN INC. GR Job# 20-640046 <br /> SWRCB,January 2006 <br /> Spill Bucket Testing Report Form NVIRONSOT" <br /> f_rn;-rLJ nr-r_n r''rk mv7k'T <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 /> Facility Name: .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 /> Name of LocalAgency Inspector i present during testing): <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: Gettler-Ryan Inc.,6805 Sierra Court Suite C,Dublin,Ca.94568 Ph.#925-551-7555 <br /> Technician Conducting Test: Tim Adams <br /> Credentials:(1) CSLB 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 Vapor 3 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" 14" <br /> Wait time between applying <br /> Irvin Irvin Irvin Irvin <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(Tt): 12:00 12:00 12:00 12:00 <br /> Final Reading(Rf) 13" 1 13" 13" 13" <br /> Test duration(Tf-Ti): I hr I fir I hr I hr <br /> Change in Reading(Rf-Ri): 0 0 0 0 <br /> Pass/Fail Threshold or Criteria: 0 0 0 0 <br /> Test Results: x Pass Fail x Pass Fail 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 /> l hereby certify that all the information eontalned in this report is true,accurate, and in full compliance with legal requirements <br /> Technician's Signature: c 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 />