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imGFTT1fR-RYAN INc. GR Job# 20-630005 <br /> 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 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 SS 1186 Date of Testing: 1/13/2015 <br /> Facility Address: 3212 N.California,Stockton,CA <br /> Facility Contact: Sarah Samuels Phone: 360-371-8111 <br /> Date Local Agency Was Notified of Testing: <br /> Name ot LocalAgency Inspector ii present during testing): Fatinah Zareef <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: Chris Sao Nicolas <br /> Credentials:(1) CSLB Contractor ICC service Tech_ SWRCB Tank Tester Other(Specify) <br /> License Number: 220793 ICC Tech Number: 5296364-UT <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: HYdrostatle Vacuum Other <br /> Test Equipment liscd: Standard Tape Measurer Equipment Resolution: 1/16" <br /> Identify Spill Bucket(Ry Tank 1 87 Master Vapor 2 87 Master Vapor 3 87 Siphon 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: 12-1 12" 12" 12" <br /> Bucket Depth: 14-- 13 1/2" 15" 13" <br /> Wait time between applying <br /> lOmin lOmin lOmin lOmin <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 1:30 PM 1:30 PM 1:30 PM 1:30 PM <br /> Initial Reading(Ri): 121- 12" 12" lift <br /> Test End Time(Tf): 2:30 PM 2:30 PM 2:30 PM 2:30 PM <br /> Final Reading(Rf) 1211 12" 12" 111t <br /> Test duration(Tf-Ti); lhr lhr lhr lhr <br /> Change in Reading(Rf-Ri): 0 0 0 0 <br /> Pass/Fail Threshold or Criteria: 0 0 0 0 <br /> Test Results: Fall Fat/ Fall Fall <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: i Date: 1/13/2015 <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 />