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v <br />TIL <br />C <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 Cf applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />ilk —ZU I A Y 16`i -0 4T7 57: IT -ii Ml <br />[am <br />cility Name. Arco 2093 date of Testing: 9/19/2014 <br />Address: 3425 Tracy Blvd., Tracy <br />cility Contact: Phone: <br />to Local Agency Was Notified of Testing: <br />of Local Agency nspectori present auring testln <br />;I► 1 ; �i : Y i it <br />Company Name: Gettler-Ryan Inc., 61105 Sierra Court Suite G. Dublin, Ca. 94 Ph.# 925-551-7555 <br />Technician Conducting Test: Chris San Nicolas <br />Credentials: (1) CSLB Q011110 for II; C service Tech. SWRCB Tank Tester Other (Spec) <br />License Number: 220793 ICC Tech Number: 52%364 -UT <br />Test Method Used: <br />99rostatic <br />Vacuum <br />Other <br />Tat Equipment Uia <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc <br />Standard Tape Measurer <br />1 87 Master Fill 2 87 Slave Fill <br />Equipment Resolution:GO <br />3 87 Siphon Fill <br />1116" <br />4 91 Fill <br />Bucket Installation Type: <br />Direct Bury <br />Contained in Sum <br />Direct Bury <br />X Contained in Sump <br />Direct Bury <br />X Contained in Sump <br />Direct Bury <br />X Contained in Sump <br />Bucket Diameter: <br />12" <br />121" <br />12" <br />12" <br />Bucket Depth: <br />14" <br />14.5" <br />14" <br />14.501 <br />Wait time between applying <br />vacuum/water and start of test: <br />lOmia <br />IOmin <br />lOmin <br />l0urin <br />Test Start Time (Ti): <br />10:05 <br />10:05 <br />10:05 <br />10:05 <br />Initial Reading (Ri): <br />10" <br />10" <br />10.5" <br />loft <br />Test End Time (Tf): <br />11:05 <br />11:05 <br />11:05 <br />11:05 <br />Final Reading (Rf) <br />10" <br />10" <br />10.5" <br />10" <br />Tat duration (Tf- Ti): <br />1hr <br />1hr <br />1hr <br />1hr <br />Change in Reading (Rf-Ri): <br />0 <br />0 <br />0 <br />0 <br />Pass/Fail old or Criteria: <br />0 <br />0 <br />0 <br />0 <br />Test Results: <br />X Falt <br />X Pass Fall <br />X Fall <br />X Pass Fail <br />Co nts - (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />CERTFICATION OF TECHNICLAN RESPONSEBLE FOR CONDUCTING TMS TESTING <br />I hereby certify that all the information contained in this repwrt Is true, accurate, and in full compliance with legal requirentgnts <br />Technician's Signature: C' ' Date: 9/19/2014 <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 />