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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 2093 Date of Testing: 12/6/11 <br /> Facility Address: 3425 Tracy Blvd.,Tracy,CA 95376 <br /> Facility Contact: Iqbal Bains Phone: 209-835-1605 <br /> Date Local Agency Was Notified of Testing: 11/8/11 <br /> Name of Local Agency Inspector(f present during testing): Thuy Tran,SJCEHD <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 Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1 87 syphon fill 2 87 syphon vapor 3 91 fill 4 91 vapor <br /> Number, Stored Product, etc.) <br /> ❑ <br /> Bucket Installation Type: Direct Bury ❑ Direct Bury El Direct Bury El Direct Bury <br /> ®Contained in Sump ®Contained in Sump ®Contained in Sump ®Contained in Sum <br /> Bucket Diameter: 12" 12" 12" 12" <br /> Bucket Depth: 14" 14" 14" 14" <br /> Wait time between applying 15 min 15 min 15 min 15 min <br /> vacuum/water and start of test: <br /> Test Start Time(Tj): 1 pm 1 pm 1 pm 1 pm <br /> Initial Reading(Rr): 13" 13" 13" 13" <br /> Test End Time(TF): 2pm 2pm 2pm 2pm <br /> Final Reading(RF): 13" 13" 13" 13" <br /> Test Duration(TF—Tr): 1 hour 1 hour 1 hour 1 hour <br /> Change in Reading(RF-Rr): 0.00 0.00 0.00 0.00 <br /> Pass/Fail Threshold or 0.00 0.00 0.00 0.00 <br /> Criteria: <br /> Test Result: ` ® Pass 0 Fail 1 0Pass ❑Fail E Pass ❑Fail S 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: 12/6/11 <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 />