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67Err1ER-RYA N INC. GR 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 Phone: 415-902-5089 <br /> Date Local Agency Was Notified of Testing: <br /> Name ot 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.H 92.5-551-7555 <br /> Technician Conducting Test: Gilbert Garcia <br /> Credentials:(1) CSLB Contractor ICC service Tech. SWRCB Tank Tester Other(Specify) <br /> License Number: 220793 ICC Tech Number: 8211864-IIT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: Hvdrostatic 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: <br /> Direct Bury Direct Bury Direct Bury Direct Bury <br /> Contained in Sump x Contained in Sump a Contained in Sump 1 Contained in Sump <br /> Bucket Diameter: 12" 12" 12" 12" <br /> Bucket Depth: 14" 14" 14" 14" <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> 5min 5min 5min 5min <br /> Test Start Time(Ti): 9:00 9:00 9:00 9:00 <br /> Initial Reading(Ri): 11.5" 11" 11.25 10.5" <br /> Test End Time(TO: 10:00 10:00 10:00 10:00 <br /> Final Reading(Ro 11.5" 11" 11.25" 10.5" <br /> Test duration(Tf-Ti): 1 hr Ilir Ilir Ihr <br /> Change in Reading(Rf-Ri): 0 0 0 0 <br /> Pass/Fail Threshold or Criteria: 0 0 0 0 <br /> Test Results: 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 /> t� <br /> EB 1 0 lull <br /> CERTFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TE NTTp�ALHEALTH <br /> !hereby certify that all the information contained in this report is true,accurate,and in full compliance with 'rr � rpHft' S�T <br /> Technician's Signature: 14 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 />