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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 for•nt anti printouts from tests(if'applicable),should be provided to the facility mi,ner/operator for submittal to the local regrJatory agency. <br /> I. FACILITY INFORMATION <br /> Facility Name: Arco 2093 Date of Testing: 12/21/2010 <br /> Facility Address: Street: 3425 Tracy Blvd. CITY:Tracy California <br /> Facilitv Contact: Ikabob Phone: 209-485-1605 <br /> Date Local Agency Was Notified of Testing: 12-7-110 <br /> Name of Local Agency Inspector(if present during testing): Thuv <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Wayne Perry <br /> Technician Conducting Test: Brandon Smith <br /> Credentials: El CSLB Contractor ❑ ICC Service Tech. ❑ SWRCB Tank Tester <br /> License Number(s): 300345 ❑ Other(Specify) <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ' Hydrostatic U Vacuum Other(S eco)) <br /> Test Equipment Used: Visual Tae Equipment Resolution: <br /> 87#1 87#2 87#3 91 <br /> Identify Spill Bucket(By Tank <br /> umber.Stored Product,etc. D Fill ❑ Vapor , Fill ❑ Vapor Fill ❑ Vapor Fill ❑ Vapor <br /> ElDirect Bury ElDirect Bury Direct Bury Direct Bury <br /> Bucket Installation Type: 21 Contained in Sump Contained in Sump Contained in Sump Z Contained in Sum <br /> Bucket Diameter: 12" 12" 12" 12" <br /> Bucket Depth: 12" 12" 12" 12" j <br /> Wait time between applying <br /> vacuum/water and start of test: 15 Minutes 15 Minutes 15 Minutes 15 Minutes <br /> Test Start Time(Ti): 9:30 9:30 9:30 9:30 <br /> Initial Reading(Rt):Inches 9.5 9.5 10 9.5 <br /> Test End Time(TF): 10:30 10:30 10:30 10:30 <br /> Final Reading(RF):Inches 9.5 9.5 10 9.5 <br /> Test Duration(TF—Tr): 1 Hour 1 Hour 1 Hour 1 Hour <br /> Change in Reading(RF-Rr): 0 0 0 0 <br /> Pass/Fail Threshold or Criteria: 0 0 0 0 <br /> Pass Fntl Pass; Earl Pass Fad Pass Fad; <br /> TesfResnit::' ❑ :;D. D ❑ ❑ ❑.... ❑: . <br /> Comments—(include information on repairs made prior to testing,and reconrntettded follow-up for failed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I herehv certify that all the information container/in this report is true,accurate,and in full compliance ivith legal requirements. <br /> Technician's Signature: t -' Date: 12/21/2010 <br /> State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements may be more stringent. <br />