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F.D.Oux 4205 <br /> Sanas CA 95�73 <br /> Co 6235-0t A-HsII <br /> jW1techP^,, , <br /> pl)[tnE 1C9 532 f=7J <br /> compt im4c, without 209-513-2b-5J <br /> ma�C_)zIft_K hpetm.carw <br /> •r;a":.alF-echptYr.�cam <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 ownedoperator 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 Vapor 2 87 Aux Vapor 3 91 Vapor 4 <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 <br /> test: <br /> Test Start Time(T,): 8:30 8:30 8:30 <br /> Initial Reading(R,): Top of Cap Top of Cap Top of Cap <br /> Test End Time(TF): 9:30 9:30 9:30 <br /> Final Reading(RF): Top of Cap Top of Cap Top of Cap <br /> Test Duration(TF—T,): 1.0 hr 1.0 hr 1.0 hr <br /> r Change in Reading(RF-R,): 0.0 0.0 0.0 <br /> Pass/Fail Threshold or Criteria: 1/16" 1/16" 1/16" <br /> Test Result: ® Pass ❑Fail ® Pass ❑Fail ® Pass <br /> ❑Fail ❑ Pass ❑ Fail <br /> Comments— (include information on repairs made prior to testing, and recommended follow-up for failed <br /> tests) <br /> a <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 />