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imGETTIER-RYAN INC. _R Job# 17200032 <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 (if applicable), should be provided to the facility owner operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Arco 6080 Date of Testing: 2/1/2017 <br /> Facility Address: 85 E. Louise Avenue, Lathrop,CA -•. <br /> Facility Contact: Daryl Lee -7—Phone: 415-902-5089 ; <br /> Date Local Agency Was Notified of Testing: <br /> tame of LocalAgency Inspector 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: Gilbert Garcia +,t T,n71 TN <br /> Credentials:(1) CSLB Contractor ICC service Tech. SWRCB Tank Tester Other(Specify) <br /> License Number: 220793 ICC Tech Number: 821186441i <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: Hydrostatic Vacuum Other <br /> Test Equipment Used: Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By Tank 1 87 Fill 2 91 Fill 3 Diesel Fill 4 87 Fill <br /> Number,Stored Product, etc.) <br /> Bucket Installation"Type: Direct Bury Direct Bury Direct Bury Direct Bury <br /> x Contained in Sump x Contained in Sump x Contained in Sump a Contained in Sump <br /> Bucket Diameter: 12" 12" 12" 12" <br /> Bucket Depth: 14" 14" 14" 14" <br /> Wait time between applying <br /> Srnin 5min 5niin Srniu <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 9:00 9.00 9.00 9:00 <br /> Initial Reading(Ri): 11.51, 11" 11.25 10.5" <br /> Test End Time(TO: 10:00 10:00 10:00 10:00 <br /> Final Reading(Rf) 11.5" 11" 11.25" 10.5" <br /> 'Test duration(Tf-Ti): 1 hr I lir l lir 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: 1 X Pass Fail X Pass Fail X Pass Fail X Pass 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 /> I hereby certify that all the information contained in this report is true,accurate,and in full compliance with legal requirements <br /> V <br /> Technician's Signature: Date: 2/1/2017 <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 />