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ED.Bex 4209 <br /> Sonars CA 95373 <br /> Ce 623511/t-ttaz <br /> Alitech.. "nt!'2C4.332-r_7:r <br /> cutupti fie widoutil Iex;2C'9t133-ZS5S3 <br /> wvati'.811"?ChP47rc:C6m <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 printouts from <br /> 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: Monday, March 12,2012 <br /> Facility Address: 85 Louise Ave. <br /> Facility Contact: Terry Phone: 209-983-9144 <br /> Date Local Agency Was Notified of Testing: 2/22/12 <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 8005930-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 Master Fill 2 87 Aux Fill 3 91 Fill 4 DSL Fill <br /> Number, Stored Product, etc. <br /> Bucket Installation Type: ❑ Direct Bury ❑ Direct Bury ❑ Direct Bury ❑ 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(Tj): 8:30 8:30 8:30 8:30 <br /> Initial Reading(111): 3 3/4"above cap 3 1/4"above cap 4 1/2"above cap 4 3/8"above cap <br /> Test End Time(TF): 9:30 9:30 9:30 9:30 <br /> Final Reading(RF): 3 3/4"above cap 3 1/4"above cap 4 1/2"above cap 4 3/8"above cap <br /> Test Duration(TF—Ti): 1.0 hr 1.0 hr 1.0 hr 1.0 hr <br /> Change in Reading(RF-Rj): 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: ® Pass ❑Fail ® Pass ❑Fail ® Pass ❑ Fail ® 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: 3/12/12 <br />