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�CTfTTLfR-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 /> FacilityName: Arco 6080 Date of Testing: 2/1/2017 <br /> Facility Address: 85 E. Louise.Avenue, Lathrop,C:1 <br /> Facility Contact: Daryl Lee Phone: 415-902-5089 <br /> Date Local Agency Was Notified of Testing: 6 ix <br /> Name of LocaFA—gency 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.#92.5-551-7555 LTH <br /> Technician Conducting Test: Gilbert Garcia Fri RT-,p,— ,t <br /> Credentials:(I) CSLB Contractor ICC service Tech. SWRCB Tank Tester Other(Specify) <br /> License Number: 220793 ICC Tech Number. 8211864-UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: tivdrostatic Vacuum Other <br /> Test Equipment Used: Standard Tape Measurer Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By Tank 1 87 2 87 3 91 4 <br /> Number,Stored Product, etc. Va or a or Va nor <br /> Bucket Installation Type: <br /> Direct Bury Direct Bury Direct Bury Direct Bury <br /> X Contained in Sump X Contained in Sump X Contained in Sump Contained in Sump <br /> Bucket Diameter: 12" 12" 12" <br /> Bucket Depth: 14" 14" 14" <br /> Wait time between applying <br /> Sorin Sorin Sniin <br /> vacuum/water and start of test: <br /> Test StartTime(Ti): 10:30 10:30 10:30 <br /> Initial Reading(Ri): 11.5" 11.51, 11.51, <br /> Test End Time(Tf): 11:30 11:30 11:30 <br /> Final Reading(Rf) 11.5" 11.5" 11.5" <br /> Test duration(Tf-Ti): 1 hr 1 hr 11►r <br /> Change in Reading(Rf-Ri): 0 0 0 <br /> Pass/Fail Threshold or Criteria: 0 0 0 <br /> Test Results: X Pass Fail X Pass Fail X Pass Fail 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 /> /hereby certify that all the information contained in this report is true,accurate,and in full compliance with legal requirements <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 />