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6ErraR-RYAN INC. R Job # 20-600041 <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: 1/28/2014 <br /> Facility Address: 3212 N California St.,Stockton,CA <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing: 1/3/2014 <br /> ,,Name of LocalAgency Inspector(i present during testing): <br /> 2.TESTING CONTRACTOR INFORMATION <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(Specify) <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---T 87 Vapor 3 91 Fill 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: 13" 14" 12" 12" <br /> Wait time between applying <br /> lOmin lOmin lOmin lOmin <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 14:00 14:00 14:00 14:00 <br /> Initial Reading(Ri): 10" I1" 9.5" 8.5" <br /> Test End Time(Tf): 15:00 15:00 15:00 15:00 <br /> Final Reading(RI) 10" 11" 9.5" 8.5" <br /> Test duration(Tf-Ti): 1hr lhr lhr lhr <br /> Change in Reading(Rf-Ri): 0 0 0 0 <br /> Pas s/FaiI Threshold or Criteria: 0 0 0 0 <br /> Test Results: X Pass Fall 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 /> All waste water generated during testing was left in waste drum onsite <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 1/28/2014 <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 />