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®/ GEmER-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 /> Facility Name: Arco 2186 Date of Testing: 1/3/2018 <br /> Facility Address: 3212 N. California Stockton 95204 <br /> Facility Contact: Dar 1 Lee Phone: 415.902.5089 <br /> Date Local Agency Was Notified of Testing: <br /> Name 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.#925-551-755.5 <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: HLdrostatie Vacuum Other <br /> Test Equipment Used: Standard Tape Measurer Equipment Resolution: I/16" <br /> Identify Spill Bucket By Tank 1 g 7-1 Vapor 2 87-2 Vapor 3 87-3 Vapor 4 91 Vapor <br /> Number,Stored Product, etc. <br /> Bucket Installation Type: <br /> trect Bury irect Bury ircct Bury irect Bury <br /> ontained in Sump contained in Sump Xcontained in Sump Xcontaincd in Sump <br /> pReading <br /> t Diameter: 1211 12F1 1211 1211 <br /> t Depth: 1211 1211 1211 1211 <br /> time between applying <br /> m/water and start of test: 5 mins 5 mins 5 mins 5 mins <br /> tart Time(Ti): 12 : 15 12 :15 12 :15 12 :15 <br /> Reading(Ri): 1111 11 1/2 1111 1 13/4 <br /> nd Time(Tf): 1:15 1 : 15 1 :15 1 :15 <br /> Reading(Rf) 11 11 1 2 1 3 11 3 4 <br /> uration(Tf-Ti): 1 hr 1hr 1 hr 1 hr <br /> e in Reading(Rf-Ri): 0 0 0ail Threshold or Criteria: 0 0 0 0 <br /> u b: a Pass an Pass ail Paas ail Pose UE211 <br /> Comments- include information on repairs made prior to testin 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 /> T �� 4 — <br /> Technician's Signature: G ZJ 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 />