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P.O.Box 4208 <br /> Sonora CA 95370 <br /> Alite chPeft a7 Ca:623541 A-Haz <br /> Phone:209-532-7320 <br /> Compliance without Compromise Fax:209-533-2650 <br /> mail@alltechpetro.com <br /> www.a l itech petro.co m <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 2133 Date of Testing: Friday,January 27, 2012 <br /> Facility Address: 2908 Benjamin Holt Dr. <br /> Facility Contact: Juan Phone: 209-478-5552 <br /> Date Local Agency Was Notified of Testing : 1/25/12 <br /> Name of Local Agency Inspector(if present during testing): Garrett Backus <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: Chad White <br /> Credentials': ® CSLB Contractor ® ICC Service Tech. ® SWRCB Tank Tester ❑ Other(Specify) <br /> License Number(s): CA: 623541 A-Haz ICC 8011608-UT SWRCB 09-1747 <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 Slave Fill 3 91 Fill 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): 13:45 13:45 14:20 <br /> Initial Reading(R): 2"above cap 1 1/2"above cap 1 1/8"above cap <br /> Test End Time(TF): 14:45 14:45 15:20 <br /> Final Reading (RF): 2"above cap 1 1/2"above cap 1 1/8"above cap <br /> Test Duration (TF—T,): 1.0 hr 1.0 hr 1.0 hr <br /> 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: ❑Fail = Pass El <br /> Fad( j E Pass arh ❑ Pass i ❑=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: 1/27/12 <br />