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9255517888 Line 4:48:21 08-26-2013 14/14 <br />s <br />(tETTLEB-RYAN Im'. GR Job # 20-591947 <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. FACiLITV INFORMATTnN <br />Facility Name: Arco 5450 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 />ame of LocalAgency Inspector i present during testing) <br />2. TESTING rONTRArTOR 1NFnRMATirnN <br />Company Name: Gettler-Ryan Inc., 6747 Sierra Court Suite J. Dublin, Co. 941%8 Ph.# 925-551-7555 <br />Technician Conducting Test: Chris San Nicolas <br />Credentials: (1) CSLB Contractor SCC service Tech. SWRCB Tank Tester Other (Specify) <br />License Number: 220793 ICC Tech Number: 5296364 -IIT <br />3_ SPI1J. RiiC'KF.T TRQTiN(_ INMUMArrTnW <br />Test Method Used: <br />Hydrostatic <br />Vacuum <br />. Other <br />Test Equipment Used: <br />Standard Tape Measurer <br />Equipment Resolution: <br />1116" <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc. <br />1 87 Main 4 <br />2 87 Siphon 3 91 4 <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 />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 />IOmin <br />IAmiu <br />IOmin <br />Test Start Time (Ti): <br />10:10 <br />12:15 <br />11:58 <br />Initial Reading (Ri): <br />13" <br />131` <br />13" <br />Test End Time (TD: <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 />lhr <br />Ihr <br />Ilir <br />Change in Reading (Rf-Ri): <br />0 <br />0 <br />0 <br />Pass/Fail Threshold or Criteria: <br />0 <br />0 <br />0 <br />0 <br />'Test Results <br />' Pass. .Fail :' .. <br />X;:Pass, ' Fad,...::. <br />X' l2ass Fail ..:...1?ass <br />.: __Phil .. <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: �'" Date: 8/2212013 <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 />