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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 fi-om tests(f 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: 8/24/10 <br /> I <br /> Facility Address: 85 E LOUISE AVENUE LATHROP,CA <br /> I <br /> Facility Contact: RAHIM Phone: 209-983-9144 <br /> Date Local Agency Was Notified of Testing: 8/10/10 <br /> Name of Local Agency Inspector(f present during testing): EHUY TRAN <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Wayne Perry <br /> Technician Conducting Test: Don Hicks <br /> Credentials': ®CSLB Contractor ❑ICC Service Tech. ❑SWRCB Tank Tester ❑Other(Specify) <br /> License Nunrber(s):300345 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ®Hydrostatic ❑Vacuum ❑ Other <br /> Test Equipment Used:Visual Tape Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1 Regular ; 2 Midgrade 3 Premium II 4 <br /> Number, Stored Product, etc.) C l i t <br /> Bucket Installation Type: ❑Direct Bury ❑Direct Bury ❑Direct Bury ❑Direct Bury <br /> N Contained in Sump N Contained in Sump ®Contained in Sump ❑Contained in Sum <br /> Bucket Diameter: 11 11 11 <br /> Bucket Depth: 12 12 12 <br /> Wait time between applying 1 hr 1 hr 1 hr <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 11:00 11:00 11:00 <br /> Initial Reading(Rr): 9" 9" 9" <br /> Test End Time(TF): 12:00 12:00 12:00 <br /> Final Reading(RF): 9" 9" 9" <br /> Test Duration(TF—Ti): 1 hr 1 hr 1 hr <br /> Change in Reading(RF-Rr): 0 0 0 <br /> Pass/Fail Threshold or 0 0 0 <br /> Criteria: <br /> Test Result: N Pass ❑ Fail N Pass ❑ Fail N Pass ❑ Fail ❑ Pass ❑ IT <br /> Comments—(include information on repairs made prior to testi)7g, and reconunended follow-up for failed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> hereby certify that all the information contained in this report is trite,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: Date:_8/24/10 <br /> r 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 />