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SWRCB, January 2006 <br />Copill 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 Date of Testing: 4/5/11 <br />Facility Address: 2908 Benjamin Holt, Stockton, CA 95207 <br />Facility Contact: Not reported I Phone: 209-478-5552 <br />Date Local Agency Was Notified of Testing: 3/3/11 <br />Name of Local Agency Inspector (if present during testing): Garrett Backus <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: Fueling & Service Technologies, Inc. (FASTECH) <br />Technician Conducting Test: Omar Ruiz ICC# 5264160 -UT <br />Credentials': X CSLB Contractor X ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other (Spec) <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 I <br />Equipment Resolution: <br />,.,,. <br />87 fill a <br />aux <br />4 87 vapor aux <br />Identify Spill Bucket (By Tann <br />Number, Stored Product, etc. <br />1 87 fill <br />2 87 vapor3 <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 />Bucket Diameter: <br />12" <br />12" <br />12" <br />12" <br />Bucket Depth: <br />16" <br />16" <br />16" <br />16" <br />Wait time between applying <br />vacuum/water and start of test: <br />15 min <br />15 min <br />15 min <br />15 min <br />Test Start Time (Ti): <br />2pm <br />2pm <br />2pm <br />2pm <br />Initial Reading (Rj): <br />14" <br />14" <br />14" <br />14" <br />Test End Time (TF): <br />3pm <br />3pm <br />3pm <br />3pm <br />Final Reading (RF): <br />14" <br />14" <br />14" <br />14" <br />Test Duration (TF — TI): <br />1 hour <br />1 hour <br />1 hour <br />I hour <br />Change in Reading (RF - RI): <br />0.00 <br />0.00 <br />0.00 <br />0.00 <br />Pass/Fail Threshold or <br />Criteria: <br />0.00 <br />0.00 <br />0.00 <br />0.00 <br />Test Result: <br />® Pass ❑ Fail <br />0 Pass ; ❑Fail <br />ED <br />Pass <br />❑ <br />Fail <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 />`C; —1 <br />Technician's Signature: <br />Date: 4/5/11 <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 />