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GErrtER-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 /> acility Name: Arco 2186 Date of Testing: 1/3/2018 <br /> acilityAddress: 3212 N. California Stockton 95204 <br /> acility Contact: Daryl Lee Phone: 415.902.5089 <br /> ate Local Agency Was Notified of Testing: <br /> ame of Localgency nspector i present during testing): <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: Alexander Tate <br /> Credentials:(1) CSLB Contractor ICC service Tech. SWRCB Tank Tester Other(Specify) <br /> License Number: 220793 ICC Tech Number: - <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: Hldrostatic Vacuum Other <br /> Test Equipment Used: Standard Tape Measurer Equipment Resolution: 1 16" <br /> Identify Spill Bucket(By Tank 1 87-1 Vapor 2 87-2 Vapor 3.87-3 Vapor 4 91 Vapor <br /> Number,Stored Product,etc.) <br /> Bucket Installation Type: irect Bury ILpirect Bury )irect Bury irect Bury <br /> X ontained in Sump QX Contained in Sump )Contained in Sump X&onWned in Sump <br /> Bucket Diameter: 1211 1211 12" 12" <br /> Bucket Depth: 1211 1211 1211 1211 <br /> Wait time between applying <br /> vacuum/waterand start oftest: <br /> 5 mins 5 mins 5 mins 5 mins <br /> Test Start Time(Ti): 12 : 15 12 :15 12 : 15 12 :15 <br /> Initial Reading(Ri): 1111 11 1/2 11" 1 13/4 <br /> Test End Time(Tf): 1:15 1: 15 1:15 1:15 <br /> Final Reading(Rf) 11 11 1/2 1/3 11 3/4 <br /> Test duration(Tf-Ti): 1 hr 1 hr 1 hr I hr <br /> Change in Reading(Rf-Ri): 0 0 0 0 <br /> Pass/Fail Threshold or Criteria: 0 0 0 0 <br /> Test Results: [RIP233 ail Paas ail I MP-ss ail M Pass ofau <br /> Comments- include information on repairs made prior to testinz and recommendedfollow-up or 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: 1 / <br /> 7 nate: 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 />