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9255517888 Line 4:26:51 09-25-2014 7/16 <br />- GEffiER-RYAN INC. Job # 10-062098.1 <br />FAZ <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 />2. TESTING CONTRACTOR INFORMATION <br />,I <br />r.hgjllaahjhAF=NT-A1 HEALTH <br />Company Name: Gettler-Ryan Inc., 6805 Sierra Court Suite G, Dublin, Ca. 94568 Ph.# 925-551-7555 <br />WEN <br />Technician Conducting Test: Chris San Nicolas EPA <br />Credentials: (1) CSLB Contractor ICC service Tech. SWRCB Tank Tester Other (Specify) <br />License Number: 220793 ICC Tech Number: 5296364 -UT <br />Test Method Used: <br />Facility Name: Arco 2093 Date of Testing: 9/19/2014 004 Be= 131 <br />Facility Address: 3425 Tracy Blvd., Tracy <br />Vacuum <br />Facility Contact: Phone: <br />Test Equipment Used: <br />Date Local Agency Was Notified of Testing: <br />Equipment Resolution: <br />tame of Local Agency Inspectori present during testing: SEP 2 5 ZUM <br />2. TESTING CONTRACTOR INFORMATION <br />,I <br />r.hgjllaahjhAF=NT-A1 HEALTH <br />Company Name: Gettler-Ryan Inc., 6805 Sierra Court Suite G, Dublin, Ca. 94568 Ph.# 925-551-7555 <br />WEN <br />Technician Conducting Test: Chris San Nicolas EPA <br />Credentials: (1) CSLB Contractor ICC service Tech. SWRCB Tank Tester Other (Specify) <br />License Number: 220793 ICC Tech Number: 5296364 -UT <br />Test Method Used: <br />Hydrostatic <br />Vacuum <br />Other <br />Test Equipment Used: <br />Standard Tape Measurer <br />Equipment Resolution: <br />1/16" <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc) <br />1 87 Master Fill <br />2 87 Slave Fill <br />3 87 Siphon Fill <br />4 91 Fill <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 />14.511 <br />1411 <br />14.5" <br />Wait time between applying <br />vacuum water and start of test: <br />lOmin <br />lOmin <br />lOmin <br />10min <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 />10" <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 />Test duration (Tf - Ti): <br />1hr <br />lhr <br />lhr <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 />X Pass Fail <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 -tip 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: L ii' ' 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 />Received Time Sep.25. 2014 2:16PM No.7150 <br />