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®GErna-RYAN Inc. GR Job# 1720-4467 <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 (:f applicable), should be provided to the facility owner operator for submittal to the local regulatory agency. <br /> 1.FACILITY INFORMATION <br /> F <br /> ility Name: Arco 2186 Date of Testing: 1 3 2018 <br /> ilityAddress: 3212 N. California Stockton 95204 <br /> ilityContact ar 1 Lee Phone: 415.902 .5089 <br /> e Local Agency Was Notified of Testing: <br /> me of LocalAgency Inspector i present during testing): <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: Gettler-11van tne.,6805 Sierra Court,Suite G,Dublin,Ca.94568 Ph.#925-551-7555 <br /> Technician Conducting Test: Alexander Tate <br /> Credentials:(1) CSLB Contractor ICC service Tech. SWRCB Tank Tester Other(Specify) <br /> License Number: 220793 ICC Tech Numbcr: 8196693-VT <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 i 2 3 4 <br /> Number,Stored Product,etc. 87-1 Fi11 87-2 F 1 11 87-3 Fill 91 Fill <br /> Bucket Installation Type: Direct Bury LjDirect Bury []Direct Bury EjDirect Bury <br /> X Contained in Sump ©C Contained in Sump ®Contained in Sump ElContained in Sump <br /> Bucket Diameter: 12 12 12 12 <br /> Bucket Depth: 12 12 12 12 <br /> Wait time between applying <br /> vacuum/waterand start oftest: <br /> 5 mins 5 mins S mins 5 mins <br /> Test Start Time(Ti): 10:00 10: 0 0 10: 0 0 10. 00 <br /> Initial Reading(Ri): 111t 11 1/2 11 3/8 10 7/8 <br /> Test End Time(Tf): 11 :00 11: 0 0 11: 0 0 11:00 <br /> Final Reading(Rf) 11" 1111 lilt 10 7/8 <br /> Test duration(Tf-Ti): 1 hr 1 hr 1 hr 1 hr <br /> Change in Reading(Rf-Ri): 0 0 0 0 <br /> Pass/Fail Threshold or Criteria: 0 0 0 0 <br /> Test Results: MPas, CYad MPass Mail M Pass OFail MPass 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 /> 1 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: 1/3/2018 <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 />