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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 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 BP 2133 1 Date of Testing: 4/19/11 <br />Facility Address: 2908 Benjamin Holt, Stockton, CA 95207 <br />Facility Contact: MANAGER I Phone: 209-478-5552 <br />Date Local Agency Was Notified of Testing: 4/13/11 <br />Name of Local Agency Inspector (fpresent during testing): GARRET BACKUS <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: Fueling & Service Technologies, Inc. (FASTECH) <br />Technician Conducting Test: Marco Godoy ICC# 5252438 -UT <br />Credentials': X CSLB Contractor X ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other (Specify) <br />License Number(s): Type - A, HAZ, C21; No. 794519 <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: ❑ Hydrostatic ❑ Vacuum X Other - Visual <br />Test Equipment Used: tape measure <br />Equipment Resolution: <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />1 91 FILL <br />Bucket Installation Type: <br />❑ Direct Bury <br />® Contained in Sump <br />❑ Direct Bury <br />❑ Contained in Sump <br />❑ Direct Bury <br />❑ Contained in Sump <br />❑ Direct Bury <br />❑ Contained in Sum <br />_ <br />Bucket Diameter: <br />13" <br />Bucket Depth: <br />14" <br />Wait time between applying <br />vacuum/water and start of test: <br />l OMIN <br />Test Start Time (TI): <br />10:00 <br />Initial Reading (R,): <br />12.5" <br />Test End Time (TF): <br />11:00 <br />Final Reading (RF): <br />12.5" <br />Test Duration (TF — Tj): <br />IHR <br />Change in Reading (RF - RI): <br />0 <br />Pass al Threshold or <br />Criteria: <br />0.00 <br />0.00 <br />0.00 <br />0.00 <br />Test Result: <br />0 Pass ❑ Fail <br />❑ Pass ❑Fail <br />❑ Pass ❑ Fail <br />❑ <br />Pass ❑ Fail . <br />Comments — (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 full compliance with legal requirements. <br />Technician's Signature: Date: 4/19/11 <br />' 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 />