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SWRCB,January 2006 <br /> Spifl Bucket Testing Deport Form <br /> This form is intended for use by contractors per forming annual testing of UST spill containment structures. The completed form 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 TNFOI?MATION <br /> FacilityName: ARCO 6080 Date of Testing: 9/9/10 <br /> Facility Address: 85 E LOUISE AVENUE LATHROP,CA <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(rfpresent during testing): EHUY TRAN <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Wayne Perry <br /> Technician Conducting Test: Don Hicks <br /> Credentials': 0 CSLB Contractor Lj ICC Service Tech. ❑S WRCB Tank Tester El Other(Spec) <br /> License Number(s):300345 <br /> 3. SPILL BUCKET TESTING INF012MATION <br /> Test Method Used: ®Hydrostatic ❑ Vacuum ❑Other <br /> Test Fquipment Used:Visual Tape Equipment Resolution: <br /> Identily Spill Bucket(By Tank 1 Regular '` 2 Midgrade 3 Premium 4 <br /> Number,Stored Product, etc, �tf"A )c rt' '�"A c l` " _ <br /> Bucket Installation Type: ❑Direct Bury ❑Direct Bury ' ❑Direct Bury' []Direct Bury <br /> ® Contained in Sump ®Contained in Sum ®Contained in Sum []Contained in Sum <br /> Bucket Diameter: Ill 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(Tj): 18:00 18:00 18:00 <br /> Initial Reading(Ri): 9" 9" 9" <br /> Test End Time(TF): 19:00 19:00 19:00 <br /> Final Reading(110: 9" 9" 9" <br /> Test Duration(TF—Tj): 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: ® Pass ❑ Fail ® Pass ❑ Fail ® Pass ❑ Fail ❑ Pass ❑ Fail <br /> CoinineI1tS—(include information on repairs made prior to testing, and recommended follow-up for failed 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 fill compliance with legal requirements. <br /> Technician's Signature: Date:_9/9/10 <br /> .l <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 />