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®GETrLER-RYAN hic. JAN X 8 2018 GR Job# 1720-4467 <br /> Spill BucketSWRCB,January 2006 <br /> r Ll �}. <br /> ��tf>��� <br /> This form is intended for use by contractors performing annual testing Wfi-:m1 'W&,ment structures. The Completed form and <br /> printouts from tests (if applicable), should be provided to the facility ownerioperator for submittal to the local regulatory agency. <br /> 1.FACILITY INFORMATION <br /> Facility Name: Arco 2186 Date of Testing: 1/3/2018 <br /> Facility Address: 3212 N. California Stockton 95204 <br /> Facility Contact: Daryl Lee Phone: 415 . 9 0 2 .5 0 8 9 <br /> Bate Local Agency Was Notified of Testing: <br /> Name of Localgency spector (if-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:(I) CSLB Contractor ICC service Tech. SWRCB Tank Tester Other(Specify) <br /> License Number: 220793 ICC Tech Number: 8196693-VT <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: llvdrostatie Vacuum Other <br /> Test Equipment Used: Standard Tape Measurer Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By Tank l 2 3 14 <br /> Number,Stored Product,etc.) 87-1 87-2 87-3 91 <br /> Bucket Installation Type: <br /> Direct Bury []Direct Bury LjDirect Bury Ljuirect Bury <br /> Contained in Sump QContained in Sump 0contained in Sump XOcontained in Sump <br /> Bucket Diameter: 12 12 12 12 <br /> Bucket Depth: 12 12 12 12 <br /> Wait time between applying <br /> vacuum/water and start of test: 5 mins 5 mins 5 mins 5 mins <br /> Test Start Time(Ti): 1700 10: 0 0 10: 00 10 :0 0 <br /> Initial Reading(Ri): 11" 11 1/2 11 3/8 10 7/8 <br /> Test End Time(Tf): 11 : 00 11: 00 11 : 00 11:00 <br /> Final Reading(Rf) ill, 1111 111, 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: ass OFall M pass Ofail Pass Fail M Pass Q 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 /> !hereby certify that all the information contained in this report is true,accurate,and in full compliance with legal requirements <br /> Technician's Signature: � l �✓� 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 />