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�GFTrCER-RYAN INC. GJJ�GE12&0108 <br /> MAR 1 WA,January 2006 <br /> Spill Bucket Testing Report Form rtVu IRCENT! !Thisform is intended for use by contractors performing annual testing of UST spill containmensures: em /sed.fo <br /> r <br /> m 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: 2/10/2015 <br /> Facility Address: 85 E Louise Ave.,Lathrop <br /> Facility Contact: Sarah Samuels Phone: 360-371-8111 <br /> Date Local Agency Was Notified of Testing: <br /> ame of LocalAgency Inspector i present during testin Michelle Henry <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: Gettler-Ryan Inc.,6805 Sierra Court Suite G,Dublin,Ca.94568 Ph.#925-551-7555 <br /> Technician Conducting Test: Chris San Nicolas <br /> Credentials:(1) CSLB Contractor ICC service Tech. SWRCB Tank Tester Other(Specify) <br /> License Number: 220793 ICC Tech Number: 5296364-UT <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: Hydrostatic Vacuum Other <br /> Test Equipment Used: Standard Tape Measurer Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By Tank 1 87 Vapor 2 87 Vapor 3 91 Vapor 4 mu <br /> Number,Stored Product,etc. <br /> Bucket Installation Type: Direct Bury Direct Bury Direct Bury Direct Bury <br /> X Contained in Sump X Contained in Sump X Contained in Sump Contained in Sump <br /> Bucket Diameter: 12" 12" 12" <br /> Bucket Depth: 16" 15.5" 15.5" <br /> Wait time between applying <br /> lOmin 10min lOmin <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 2:45 2:45 2:45 <br /> Initial Reading(Ri): 14" 13" 14" <br /> Test End Time(Tf): 3:45 3:45 3:45 <br /> Final Reading(Rf) 14" 13" 14" <br /> Test duration(Tf-Ti): Ihr lhr Ihr <br /> Change in Reading(Rf-Ri): 0 0 0 <br /> Pass/Fail Threshold or Criteria: 0 0 0 <br /> Test Results: X Pass Fail X PassFall X Pass Fail Pass Fail <br /> Comments-(include information on repairs made prior to testing,and recommended follow-upforfailed tests) <br /> CERTFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> /hereby certify that all the information contained in this report is true,accurate,and in full compliance with legal requirements <br /> i <br /> Technician's Signature: i Date: 2/10/2015 <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 />