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9255517888 <br />Line <br />4:26:21 <br />09-25-2014 6/16 <br />CIETPLER-RYAN <br />A <br />INc. <br />3 87 Siphon Vapor <br />G Job # <br />10-06209$,1 <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: <br />Facility Address: 3425 Tracy Blvd., Tracy <br />?acility Contact: Phone: <br />Date Local Agency Was Notified of Testing: <br />ame -of Local Agency Inspector (i present during testing) : <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: Gettler-Ryan Inc., 6805 Sierra Court Suite G, Dublin, Ca. 94568 PhA 925-551-7555 <br />Technician Conducting Test: Chris San Nicolas <br />Credentials: (1) CSLB Contractor ICC service Tech. SWRCB Tank Tester <br />License Number. 220793 ICC Tech Number: 5296364 -UT <br />3. SPILL BUCKET TESTING iNFORMATinN <br />Other <br />Test Method Used: Hydrostatic 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 />-7 <br />1 87 Master Vapor <br />11 <br />2 87 Slave Vapor <br />1 <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 />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 />12" <br />12" <br />12" <br />Bucket Depth: <br />14" <br />14.5" <br />14" <br />15.25" <br />Wait time between applying <br />vacuum water and start of test: <br />10min <br />10min <br />IOmin <br />10min <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 />10.5" <br />10.5" <br />10.5" <br />Test End Time (Tf): <br />3:30 <br />3:30 <br />3:30 <br />3:30 <br />Final Reading (Rf) <br />10.5" <br />10.5" <br />10.5" <br />10.5" <br />Test 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 Threshold or Criteria: <br />0 <br />0 <br />0 <br />0 <br />Test Results: <br />% Pass Fait <br />X Pass Fail <br />X Pass Fail <br />X Pass 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/I9/2014 <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 />Received Time Sep -25. 2014 2:16PM No.7150 <br />ul <br />