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01/1712009 07:13 2098873408 <br />11 <br />SWRCB, Jammy 2006 <br />Spill Bucket 'Vesting Report Form <br />nix form is intended for use by cvntractors performing annual tesitng of UST spill contaimwnt structures The completed form and <br />printouts ftom tests (if applicable), should be provided to the facility owner/operator, for submittal io the lxal regulatory agemy. <br />1. FACILITY INMRMAITON <br />Facility Name: Arco I Date of Tesft: 5-23-11 <br />hacift Addms: 444 Mowdale Rd LaAhn % CA <br />Facility Contact Phone: <br />Date Local Agency Was Notified of Testing <br />Name of Local Agency Inspector ffp=0 &wing g): NOMMY <br />2 7V-cTilvr_ r[)'t1tTRA(TMU iNWnRMATiON <br />Cody Name: Headman <br />Tecbnician Conducting Test: Gavin iN'A iarns _ <br />Cndevhals' : Pq CSLB Contractor Pq ICC Service Tech ❑ SWRCB Tats Tester 0 (kW (Specify) <br />License Number(s): CSLB:856771 ICC: 5016288 <br />�r_4. <br />Test lvle" Used: X Hydrostatic 0 Vann 0 Otbrt <br />Test Equipment Used: Water Equipment Resolution: <br />Identify Spill Bucket (By Tank 1-87 <br />,Number, Stored Pioduct, etc. <br />2-91 3- <br />a <br />Budwt Installation Type: X Direct Bury <br />❑ ConWnod in <br />XD!rectfty X Dkect Bary <br />❑ Containod in§nT ❑ Comahied in Sump <br />0 Dior+ect Bury <br />❑ ContaiaM in $ <br />Bucket Diameter. 11" <br />11" 11" <br />Bucket Depth. 10%11 <br />111/41,1277 <br />Watt L^ me between appb* 1 tir <br />vacnnntwater and start of ter: <br />I bar l lir <br />Test Start Time (Tr): I <br />1 1 <br />7saitial Reading Otj): 9 W." <br />9 3/," 10 %7,P <br />Tait End Time (Tg): 2 <br />2 2 <br />FinalReading (fie) 8,/771: <br />93141' 10 W, <br />Test Duration UP — TO: I b�udr <br />1 lir 1 hr <br />Chamige in (Rr-R�: 0 <br />0 0 <br />PasWFai1 ThreshoM or Pass <br />Criteria: <br />Pass Fars <br />Test Result:° X" an :q Fni1.. <br />XP :..I� Fail :: X Its . CTpail , <br />Q. Pa" <br />Comments — (include infornraliorr on repairs made prior to testing and recommendedfollow-u for failed tests] <br />CERT)iI+'I[CA,TION OF TEC RCIAN RESPONSERLE WOR CONDUCTING TM TESTING <br />I hereby cenfy tha all the Amfw7nafma confahwd in this repvR is axd iu]rill cmTfianw uo legat /7agttbwne7ift <br />Tecbnic iaan.'s Sigaatxnre:JDate: -� W l L <br />State lags and regulations do not cmmmly require tesfiug to be peribruted by a quafified =U=W. However, local regWremem <br />rn,imy h- mfwp cN4"no"+ <br />