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GETTtER-RYAN INc. <br />Jab # 20-632266 <br />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 2093 Date of Testing: 9/8/2015 <br />Facility Address: 3425 Tracy Blvd Tracy, CA <br />Facility Contact: Phone: <br />Date Local Agency Was Notified of Testing: 8/18/2015 <br />Name of LocalAgency Inspector (if -present wring testing) : f atinah ?areef 7P 15 2 <br />2. TESTING CONTRACTOR INFORMATION ENVIBONMELEML <br />Company Name: Gettler-Ryan Inc., 6805 Sierra Court Suite G, Dublin, Ca. 94568 Ph.# 925-551-755.5e�" 0,gQT%AChj-T <br />Technician Conducting Test: Chris San Nicolas <br />Credentials: (1) C,SLB Contractor ICC service Tech. SWRCB Tank Tester Other (Specify) <br />License Number: 220793 ICC Tech Number: 5296361 -UT <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: llvdrostatic Vacuum Other <br />Test Equipment Used: Standard Tape Measurer Equipment Resolution: 1/16" <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />1 87 Main Vapor <br />2 87 Slave Vapor <br />3 87 Siphon Vapor <br />4 91 Vapor <br />Bucket Installation Type: <br />Direct Bury <br />x Contained in Sump <br />Direct Bury <br />Y Contained in Sump <br />Direct Bury <br />x Contained in Sump <br />Direct Bury <br />x Contained in Sump <br />Bucket Diameter: <br />13" <br />13" <br />13" <br />13" <br />Bucket Depth: <br />16" <br />16" <br />16" <br />16 -- <br />Wait time between applying <br />vacuum/water and start of test: <br />IOmin <br />lOmin <br />IOmiu <br />lOmin <br />Test Start Time (Ti): <br />12:00 <br />12:00 <br />12:00 <br />12:00 <br />Initial Reading (Ri): <br />11" <br />1 I" <br />fill <br />I I" <br />Test End Time (Tf): <br />13:00 <br />13:00 <br />13:00 <br />13:00 <br />Final Reading (Rf) <br />I1" <br />11'- <br />I1'- <br />ill, <br />Test duration (Tf - Ti): <br />I hr <br />I hr <br />I hr <br />1 hr <br />Change in Reading (Rf-Ri): <br />0 <br />0 <br />0 <br />0 <br />Pass/Fail Threshold or Criteria: <br />0 <br />0 <br />0 <br />0 <br />Test Results: <br />X "Pass I Fail . <br />.X Pass Fail <br />X Pass . Fail <br />X Pass I Fail <br />Comments - (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />CERTFICATION 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: 9/8/201.5 <br />(1) 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 />