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9255517888 Line 1 :16:36 11-18-2013 6/17 <br />CtETTLER-RYAN IMC. 0 <br />� 3 <br />SWRCB, January 2006 <br />Spill Bucket Testing Report Form N Q V 18 2013 <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 sub agency. <br />I _ VArT1.TTV 1?jWnDMATTnxT TTH EPA T `r <br />aeility Name: Arco 2093 Date of Testing: 11/14/2013 <br />Facility Address: 3425 Tracy Blvd., Tracy, CA <br />Facility Contact: Phone: <br />Date Local Agency Was Notified of Testing: <br />Name of LocalAgency Inspector(typresent duFthg testing): Thuy Tran <br />2. TF.CTTNr_ rn %TTD A r't`nD TV VnnXX A mad -610 <br />Company Name: Gettler-Ryan Inc., 6747 Sierra Court Suite J, Dublin, Ca. 94568 Ph.# 925-551-7555 <br />Technician Conducting Test: Chris San Nicolas <br />Credentials: (1) SLB Contractor ICC service Tech. SWRCB Tank Tester Other (Spec) <br />License Number: 220793 ICC Tech Number: 5296364 -UT <br />Test <br />Number <br />Bucket Installation Type: <br />Bucket Diameter. <br />Bucket Depth: <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (Ti): <br />Initial Reading (Ri): <br />Test End Time (Tf): <br />Final Reading (Rf) <br />Test duration (Tf - Ti): <br />Change in Reading (Rf-Ri): <br />PaWFail Threshold or Criteria: <br />3. SPILL BUCKET TESTING INFORMATION <br />1 87 Fill <br />2 87 Fill <br />3 87 Fill <br />4 91 Fill <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 />1211 <br />12" <br />1211 <br />1211 <br />10.51, <br />1011 <br />200, <br />10" <br />10min <br />10min <br />10min <br />10min <br />9:30 <br />9:30 <br />9:30 <br />9:30 <br />1011 <br />9.511 <br />9.511 <br />93/410 <br />10:30 <br />10:30 <br />10:30 <br />10:30 <br />10" <br />9.511 <br />9.5" _ <br />93/411 <br />1hr <br />lhr <br />1hr <br />lhr <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />X Pass Pall <br />X Pass . Fail <br />X -Pass Fain <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 TIM TESTING <br />I hereby certify that all the hiformation contained in this report is true, accurate, and in full compliance with legal requirements <br />Technician's Signature: Date: 11/14/2013 <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 />