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92555,17888 Line 1 08:50:03 01-20-2015 6/17 <br /> j GEITLER-RYAN INC. .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 2186 Date of Testing: 1/13/2015 <br /> Facility Address: 3212 N.California,Stockton,CA <br /> ----------— <br /> _.. — <br /> Facility ontact:Sarah Samuels --Phone:Phone: 360-371=5111- i� -��� ® <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local-Agency Inspector(ifpresent during testing): Fatinah Zareef 5 <br /> 2.TESTING CONTRACTOR INFORMATION T^ <br /> Company Name: Gettler-Ryan Inc.,6805 Sierra Court Suite G,Dublin,Ca.94568 Ph.#925-551-7555 t!C 1r CAIT <br /> Technician Conducting Test: Chris San 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.SPILT,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 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" 12" 12" 12" <br /> Bucket Depth: 14" 13 1/2" 15" 13" <br /> Wait time between applying <br /> 10min 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): 12" 12" 12" 11" <br /> Test End Time(Tf): 2:30 PM 2:30 PM 2:30 PM 2:30 PM <br /> Final Reading(Rf) 12" 12" 12" 11" <br /> Test duration(Tf-Ti): 1hr lhr lhr Ihr <br /> Change in Reading(Rf-Ri): 0 0 0 0 <br /> Pass/Fail Threshold or Criteria: 0 0 0 0 <br /> Test Results: Fail Fall Fail Fail <br /> Continents-(include information on repairs made prim to testing,and recommended follow-up forfailed 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 />