Laserfiche WebLink
C <br />i fj� <br />�;., <br />� ♦• ! is 1'' <br />SWRCB, January 2006 <br />Spill Bucket Testing eort 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 ownerloperator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />acidity Name: Arco 2093 Date of Testing: 9/19/2014 <br />aciiity Address: 3425 Tracy Blvd., Tracy <br />acility Contact: Phone. <br />Date Local Agency Was Notified of Testing: <br />arae of Local Agency Inspector Fi7present during testing): <br />Company Name: Gettler-Ryan Inc., 6805 Sierra Court Suite G, Dublin, Ca. % PhA 925-551-7555 <br />Technician Conducting Test: Chris San Nicolas <br />Credentials: (1) CSLB Contractar ffic w3ft Tech. SWRCB Tank Tester Other (Spec) <br />License Number: 220793 ICC Tech Number: 5296364 -UT <br />est Method Used: <br />Hvdr Nc <br />Vacuum <br />Other <br />ui ent Used: <br />Standard Ta Measurer <br />E ui ent Resolution: <br />1/16" <br />entify Spill Bucket (By rank <br />umber, Stored Product, e <br />IT <br />1 87 Master Vaptc. or <br />2 87 Stave Vapor <br />3 87 Siphon Vapor <br />4 91 Vapor <br />Bucket Installation Type: <br />Direct Bury <br />Contained in Sump <br />Direct Bury <br />X Contained in Sump <br />Direct Bury <br />X Contained in Sump <br />Direct Bury <br />X Contained in Sum <br />Bucket Diameter: <br />12" <br />12" <br />120/ <br />12" <br />Bucket Depth: <br />14" <br />143" <br />14" <br />15.251, <br />Wait time between applying <br />vauum/water and start of test: <br />c <br />10mnn <br />10min <br />IOmin <br />l0eain <br />Test Start Time (Ti): <br />2:30 <br />2:30 <br />2:30 <br />2:30 <br />Initial Reading (Ri): <br />10.5" <br />103°' <br />10.51, <br />10.50, <br />Test End Time (Tf): <br />3:30 <br />330 <br />3:30 <br />3:30 <br />Final Reading (Rf) <br />10.5" <br />10.50, <br />10.5" <br />10.5" <br />Test duration (Tf - Ti): <br />lbr <br />Il r <br />Ihr <br />1hr <br />Change in Reading (Rf-Ri): <br />0 <br />0 <br />0 <br />0 <br />PasslFaid Threshold or Criteria: <br />0 <br />0 <br />0 <br />0 <br />Test <br />X Pass Fag <br />X Pass Fag <br />X Pass Fail <br />aamcnz� <br />X Pass Fag <br />Comments - (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />CERTIFICATION OF TECHNICIAN RESPONSEBLE FOR CONDUCTING THIS TESTING <br />1 hereby certo that all the information contained in this report Is true, accurate, and in full compliance with legal requirements <br />Technician's Signature: L <br />Date:: 9/19/2014 <br />(1) State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirernents <br />may be more stringent. <br />