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®GFTTLER-RYAN INC. 7 iZ; <br /> J A N IJanuary 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intended for use by contractors performing annual testing of UST spill comeft* 0WAFNTALc+,VMh*4t7 rm and <br /> printouts from tests (if applicable), should be provided to the facility ownerioperator for submittl)WOe-.lQggb *tory 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: 415.902.5089 <br /> Date Local Agency Was Notified of Testing: <br /> ame of Localgency Inspector i present during testin <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: Il drostatic Vacuum Other <br /> Test Equipment Used: Standard Tape Measurer Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By Tank 1 2 3 4 <br /> Number,Stored Product,etc. 8 -1 87-2 87-3 91 <br /> Bucket Installation Type: <br /> irect Bury irect Bury irect Bury irect Bury <br /> ontained in Sump Mcontained in Sump Xcontained in Sump Xaontained in Sump <br /> Bucket Diameter: 1211 1211 1211 12" <br /> Bucket Depth: 1211 12" 127' 12" <br /> Wait time between applying <br /> [Final <br /> cuum/water and start of test: 5 mins 5 mins 5 mins 5 mins <br /> st Start Time(Ti): 12 : 15 12 :15 12 :15 12 :15 <br /> itial Reading(Ri): 1111 11 1/2 11" 1 13 4 <br /> st End Time(Tf): 1 : 15 1 :15 1:15 1 :15 <br /> Reading(Rf) 11 11 1 2 1 3 11 3 4st duration(Tf-Ti): 1 hr 1 hr 1 hr 1 hr <br /> Change in Reading(R.f--Ri): 0 0 0 0 <br /> Pass/Fail Threshold or Criteria: 0 0 0 0 <br /> Test Results: Pass ai! Pass ail Pass ail Pass ail <br /> Comments- include information on repairs made prior to testing,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: �/ Gam; �..u�' 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 />