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n <br />R D. 8ux 4206 <br />Sonora CA 95370 <br />Ca: 6235,11 MHaz <br />Phone: 2C9-532-7320 <br />Fax: 2o9-53j-z35u <br />ma I;:)alhxhpetrc.com <br />M-kv.a11xhpetrc.com <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 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 5450 Date of Testing: Thursday, August 30, 2012 <br />Facility Address: 1617 W. Fremont St. <br />Facility Contact: Karen Phone: 209-462-1617 <br />Date Local Agency Was Notified of Testing : 8/6/12 <br />Name of Local Agency Inspector (if present during testing): Stacy Rivera <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: Chad White <br />Credentials': ® CSLB Contractor ® ICC Service Tech. ® SWRCB Tank Tester ❑ Other (Specify) <br />License Number(s): CA: 623541 A-Haz ICC 8152115 -UT SWRCB 09-1747 <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 />Identify Spill Bucket (By Tank 1 87 Master Fill <br />Number, Stored Product, etc. <br />2 87 Syphon Fill <br />Equipment Resolution: <br />lsloom <br />3 91 Fill <br />1/16" <br />4 <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 />Test Start Time (T,): <br />10:45 <br />10:45 <br />9:20 <br />Initial Reading (R): <br />3 3/8" above cap <br />3 1/2" above cap <br />4 5/8" above cap <br />Test End Time (TF): <br />11:45 <br />11:45 <br />10:20 <br />Final Reading (RF): <br />3 3/8" above cap <br />3 1/2" above cap <br />4 5/8" above cap <br />Test Duration ('F — T,): <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 />Pass/Fail Threshold or Criteria: <br />1/16" <br />1/16" <br />1/16' <br />Test Result: <br />® .Pass : ❑ Fail : <br />S Pass , Q Fail <br />-, ,-„�' Pass„ ❑. Fail <br />❑ , Pass Q Fail <br />Comments — (include information on repairs made prior to testing, and recommended follow-up for failed <br />tests) <br />Both 87 Fill buckets needed cleaning at the drain valve and to had leaking caps. <br />Both passed on second test. <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: <br />Date: 8/30/12 <br />