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9255517888 Line 1 SO Bucket Testing Report Fc� 0 03 a.m. 12-16-2009 2/3 <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 />l.. FACILITY INFORMATION <br />Facility Name: Arco #5450 Date of Testing: 12/3/09 <br />Facility Address: 1617 Fremont St, Stockton Ca <br />Facility Contact: Site Attendant Phone: (209) 462-1617 <br />Date Local Agency Was Notified of Testing: 11/19/09 <br />Name of Local Agency Inspector (rf present during testing): Ray Von Flue <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: Gettler-Ryan Inc. <br />Technician Conducting Test: Chris Bishop 8010969 -UT <br />Credentials': X CSLB Contractor ❑ ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other (Spec) <br />License Number(s): 220793 <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: X Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: Tape Measure <br />Equipment Resolution: 1/16" <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc. <br />1 - 87 Master <br />2 <br />3 <br />4 <br />Bucket Installation Type: <br />❑ Direct Bury <br />X Contained in Sump <br />❑ Direct Bury <br />❑ Contained in Sump <br />❑ Direct Bury <br />❑ Contained in Sump <br />❑ Direct Bury <br />❑ Contained in Sum <br />Bucket Diameter: <br />12" <br />Bucket Depth: <br />14" <br />Wait time between applying <br />vacuum/water and start of test: <br />I min <br />Test Start Time (Tj): <br />1:05pm <br />Initial Reading (Ri): <br />13" <br />Test End Time (TF): <br />2:05pm <br />Final Reading (RF): <br />13" <br />Test Duration (TF — Tj): <br />lhr <br />Change in Reading (RF - Rj): <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />0 <br />Test Regult: <br />X .Pass ❑ Fail <br />❑ Pass ❑ Fail <br />❑ Pass: n Fail <br />❑ Pass ❑ Fail <br />Comments — (include information on repairs made prior to testing, and recommended fallow -up for failed tests) <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: <br />' 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 />