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Ll <br />AfltechPetrbo <br />compliance without compromise <br />Spill Bucket Testing Report Form <br />P.O. Bux 4206 <br />Sonora CA 95370 <br />Ca: 623511 A-Hm <br />Phone: 2C9-532-1329 <br />I ax; 2Q9-5JJ-2'a5U <br />ma I�)all:echpetrc.com <br />­"kv.all.echpetre.com <br />This form is intended for use by contractors performing annual testing of UST spill containment structures. The completed form and printouts from <br />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: Wednesday, November 28, 2012 <br />Facility Address: 3425 Tracy Blvd Tracy, Ca 95376 <br />Facility Contact: Iqbas Bains Phone: 209-835-1605 <br />Date Local Agency Was Notified of Testing : 10/10/12 <br />Name of Local Agency Inspector (if present during testing): Thuy Tran <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: Alltech Petro Inc, P.O. Box 4208, Sonora CA 95370. (209) 532-7320 <br />Technician Conducting Test: Isaac Anderson <br />Credentials': ® CSLB Contractor ® ICC Service Tech. ® SWRCB Tank Tester ❑ Other (Specify) <br />License Number(s): CA: 623541 A-Haz ICC 8005930 -UT SWRCB 09-1749 <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: <br />® Hydrostatic <br />❑ vacuum <br />❑ Other <br />Test Equipment Used: One Hour observed test <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 Syphon Fill <br />4 91 Fill <br />Bucket Installation Type: <br />❑ Direct Bury <br />® In Sump <br />❑ Direct Bury <br />In Sump <br />❑ Direct Bury <br />In Sump <br />❑ Direct Bury <br />In Sum <br />Wait time between applying <br />vacuum/water and start of <br />test: <br />0 <br />0 <br />0 <br />0 <br />Test Start Time (T,): <br />11:05 <br />11:05 <br />11:05 <br />11:05 <br />Initial Reading (R,): <br />2 7/8" above cap <br />2 3/4" above cap <br />3 1/8" above cap <br />2 5/8" above cap <br />Test End Time (TF): <br />12:05 <br />12:05 <br />12:05 <br />12:05 <br />Final Reading (RF): <br />2 7/8" above cap <br />2 3/4" above cap <br />3 1/8" above cap <br />2 5/8" above cap <br />Test Duration (TF —Ti): <br />1.0 hr <br />1.0 hr <br />1.0 hr <br />1.0 hr <br />Change in Reading (RF -R,): <br />0.0 <br />0.0 <br />0.0 <br />0.0 <br />Pass/Fail Threshold or Criteria: <br />1/16" <br />1/16" <br />1/16" <br />1/16" <br />Test Result: <br />® Pass ❑ Fail <br />® Pass ❑ Fail <br />® Pass ❑ Fail <br />® Pass ❑ Fail <br />Comments — (include information on repairs made prior to testing, and recommended follow-up for failed <br />CERTIFICATION 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: 3/2/12 <br />