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9255517888 Line 15:01:52 01-14-2014 4/8 <br /> GBTTLfR-RYAN INC. Job # 20-592714 <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 2186 Date of Testing: 1/8/2014 ,® <br /> Facility Address: 3212 N California St Stockton,CA <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing: 12/31/2013 20.4 <br /> i.Name of LocalAgency Inspector(i present during testing) <br /> AVIRONMEN <br /> 2.TESTING CONTRACTOR INFORMATION TAL <br /> Company Name: Gettler-Ryan Inc.,6747 Sierra Court Suite J,Dublin,Ca.94568 Ph.#925-551-7555 <br /> Technician Conducting Test: Chris San Nicolas <br /> Credentials: (1) CSLB Contractor ICC service Tech. SWRCB Tank Tester Other(Spec) <br /> License Number: 220793 ICC Tech Number: 5296364-UT <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 Fill 2 87 Fill3 87 Fill 4 91 Fill <br /> Number,Stored Product, etc. <br /> Bucket Installation Type: <br /> 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: 13.5" 14" 14" 13" <br /> Wait time between applying <br /> lOmin lOmin lOmin lOmin <br /> vacuwn/water and start of test: <br /> Test Start Time(Ti): 9:00 9:00 9:00 9:00 <br /> Initial Reading(Ri): 11" 11" 11" 11" <br /> Test End Time(Tf): 10:00 10:00 10:00 10:00 <br /> Final Reading(Rf) 11" 11" 11" 11" <br /> Test duration(Tf-Ti): lhr 1hr 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 ' 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 far jailed 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: Date: 1/8/2014 <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 /> Received Time Jan. 14. 2014 1 : 53PM No. 5018 <br />