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GFTTI.fR-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 (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />I;:O E74 9 ISM <br />Facility Name: Arco 5450 Date of Testing: 8/2212013 <br />Facility Address: 1617 Fremont St., Stockton <br />Facility Contact: Phone: <br />Date Local Agency Was Notified of Testing: 7/1812013 <br />Fa—me of LocalAgency Inspector i present uring testing) <br />/► I r 1<:u: IBJ <br />Company Name: Gettier-Ryan Inc.. 6747 Siena 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: <br />1/16" <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc. <br />1 87 Main Vapor <br />2 87 Siphon Vapor <br />3 91 Vapor 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 />Bucket Depth: <br />10.51, <br />121, <br />10.51, <br />12" <br />10.51° <br />12" <br />Wait time between applying <br />vacuum/water and start of test: <br />I Omin <br />IOmin <br />lOmin <br />Test Start Time (Ti): <br />13:35 <br />13:35 <br />13:35 <br />Initial Reading (Ri): <br />11.51, <br />fit, <br />11" <br />Test End Time (Tt): <br />14:35 <br />14:35 <br />14:35 <br />Final Reading (Rf) <br />11.51' <br />111, <br />111, <br />Test duration (Tf - Ti): <br />I hr <br />1 h r <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 <br />0 <br />Test Results: <br />X Pass Fail <br />X Pass Fail <br />X Pass Fail <br />Pass Fail <br />Comments - (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />OPW Spill Buckets <br />x'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 />