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v <br />&Erraft-RYAN INC. <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 (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />FacilityName: Arco 54.40 Date of Testing. 8/22/2013 <br />Facility Address: 1617 Fremont St„ Stockton <br />Facility Contact: Phone: <br />Date Local Agency Was Notified of Testing: 7/18/2013 <br />Name of Local Agency inspector i present during testing): <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) 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: 1/16" <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc. <br />1 87 Main <br />.. , <br />2 87 Siphon <br />,. - . d _ . .,�. W <br />3 91 4 <br />Bucket Installation Type: <br />Direct Bury <br />Contained in Sump <br />Direct Bury <br />X Contained in Sump <br />Direct Bury Direct Bury <br />X Contained in Sump Contained in Sump <br />Bucket Diameter: <br />10.5 <br />10.5 <br />10.5 <br />Bucket Depth: <br />14.5 <br />14.5 <br />14.5 <br />Wait time between applying <br />vacuum/water and start of test: <br />10min <br />lOmin <br />lOmin <br />Test Start Time (Ti): <br />10:10 <br />12:15 <br />11:58 <br />Initial Reading (Ri): <br />13" <br />13" <br />13" <br />Test End Time (Tf): <br />11:10 <br />1:15 <br />12:58 <br />Final Reading (Rf) <br />13" <br />13" <br />13" <br />Test duration (Tf - Ti): <br />1 fir <br />1 hr <br />1 hr <br />Change in Reading (Rf-Ri): <br />0 <br />0 <br />0 <br />Pass/Fail Threshold or Criteria: <br />0 <br />0 <br />0 0 <br />Test Results: <br />X Pass Fail <br />X Pass Fail <br />X Pass Fail Pass Fail <br />Comments - (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />OPW Spill Buckets <br />*87 siphon & 91 spill buckets failed initial test <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: <br />Date: 8/22/2013 <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 />