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�6,r7TL r-RYAN live. GR Job# 20-640102 <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: 2/22016 <br /> Facility Address: 85 E Louise Ave..Lathrop <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing: 12/2912015 <br /> ame o oca Agency Inspector i present during testing): <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: Gettler-Kyan Inc..6805 Siena C.uurt Suite(.,Dublin,Ca.94x68 Ph.4 925-551-7555 <br /> Technician Conducting Test: Tim Adams <br /> Credentials:(1) CSLB Contractor ICC service Tech, SWRCB Tank Tester Other(Spec) <br /> License Number: 220793 ICC Tech Number: x105730 <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: Flvdrustatic Vacuum Other <br /> Test Equipment Used: Standard Tape Measurer Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By Tank 1 87 Vapor 2 91 Vapor 3 4 <br /> Number,Stored Product,etc.) <br /> Bucket Installation Type: Direct Bury Direct Bury Direct Bury Direct d1ump <br /> X Contained in Sump x Contained in Sump Contained in Sump Contai <br /> Bucket Diameter: 12" 12" <br /> Bucket Depth: 14" 14" <br /> Wait time between applying <br /> vacuurnlwater and start of test: f ruin Imin <br /> Test Start Time(Ti): 11:30 11:30 <br /> Initial Reading(Ri): 12" 12" <br /> Test End Time(Tn: 12:30 12:30 <br /> Final Reading(Rf) 12" 12" <br /> Test duration(Tf-Ti): 1 hr I hr <br /> Change in Reading(Rf-Ri): 0 0 <br /> Pass/FaiI Threshold or Criteria: 0 0 {1 Test Results: ?► Pass Fail X Pass Fail Pass Fail Pass <br /> Comments-(include information on repairs made prior to testing,and recommended follow-up for failed tests) MAR . <br /> f <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: `'-` — S` <br /> Date: 2/2/2016 <br /> (t) 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 />