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P.O.Box 4208 <br /> AlltecheL Sonora 4195370 <br /> ne:209-53 -7320 <br /> Phone:209-532-7320 <br /> Compliance without Compromise Fax:209-533-2650 <br /> mail@alltechpetro.com <br /> www.alltechpetro.com <br /> Fill 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 printouts from <br /> tests(if applicable),should be provided to the facility owner/operator for submittal to the local regulatoryagency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Arco#6080 Date of Testing: Thursday, February 28, 2013 <br /> Facility Address: 85 Louise Ave. Lathrop, Ca 95330 <br /> Facility Contact: Terry Phone: 209-983-9144 <br /> Date Local Agency Was Notified of Testing : 01-23-2013 <br /> Name of Local Agency Inspector (if present during testing): Thuy Tran <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Alltech Petro Inc, P.O. Box 4208, Sonora CA 95370. (209) 532-7320 <br /> Technician Conducting Test: Isaac Anderson <br /> Credentials': ® CSLB Contractor ® ICC Service Tech. ® SWRCB Tank Tester ❑ Other (Specify) <br /> License Number(s): CA:623541 A-Haz ICC 8146912-UT SWRCB 09-1749 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br /> Test Equipment Used: One Hour observed test Equipment Resolution: 1/16" <br /> Identify Spill Bucket (By Tank 1 87 Quad Fill 1 2 87 Quad Fill 2 3 91 Fill 4 DSL Fill <br /> Number, Stored Product, etc.) <br /> Bucket Installation Type: <br /> El Direct Bury El Direct Bury El Direct Bury El Direct Bury <br /> ® In Sump In Sump In Sump In Sum <br /> Wait time between applying <br /> vacuum/water and start of 0 0 0 0 <br /> test: <br /> Test Start Time(T): 9:00 am 9:00 am 9:00 am 9:00 am <br /> Initial Reading (R): Top of Cap Top of Cap Top of Cap Top of Cap <br /> Test End Time(TF): 10:00 am 10:00 am 10:00 am 10:00 am <br /> Final Reading (RF): Top of Cap Top of Cap Top of Cap Top of Cap <br /> Test Duration (TF—T,): 1.0 hr 1.0 hr 1.0 hr 1.0 hr <br /> Change in Reading (RF-R,): 0.0 0.0 0.0 0.0 <br /> Pass/Fail Threshold or Criteria: 1/16" 1/16" 1/16" 1/16' <br /> Test Result: I ® Pass ❑ Fail ® Pass ❑ Fail I ® Pass ❑ Fail I ® Pass ❑ Fail <br /> Comments — (include information on repairs made prior to testing, and recommended follow-up for failed <br /> tests) <br /> CERTIFICATION 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: Date: 02-28-2013 <br />