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0 0 <br /> ®GFTnfR-RYAN lNc. GR Job# 20-641524 <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.FACILITY INFORMATION <br /> Facility Name: Arco SS.54.50 Date of Testing: 7/26/2016 <br /> Facility Address: 1617 W. Fremont.Stockton,CA <br /> Facility Contact: Sarah Samuels Phone: 360-526-3917 <br /> Date Local Agency Was Notified of Testing: <br /> ame of LocalAgency Inspector-7present during testing): <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: Gettler-Ryan Inc..6805 Sierra Court Suite G,Dublin,Ca.94568 Ph.9 925-551-7555 <br /> Technician Conducting Test: Elodio Sanchez <br /> Credentials:(1) CSLB Contractor ICC service Tech. SWRCB Tank Tester Other(Specify) <br /> License Number: 220793 ICC Tech Number: 8126818-UT <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: Hvdrostatic Vacuum Other <br /> Test Equipment Used: Standard Tape Measurer Equipment Resolution: 1/I6" <br /> Identify Spill Bucket(By Tank87-1 2 87-2 3 91 4 <br /> IF7 <br /> Number,Stored Product, etc.) Vapor Va or N a por <br /> Bucket Installation Type: Direct Bury Direct Bury Direct Bury Direct Bury <br /> r Contained in Sump x Contained in Sump a Contained in Sump Contained in Sump <br /> Bucket Diameter: 12" 12" 12" <br /> Bucket Depth: 1.5" 15" 15" <br /> Wait time between applying <br /> lOmin lOmin 10min <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 11:00 11:00 11:00 <br /> Initial Reading(Ri): 10" 10 1/2" 10" <br /> Test End Time(Tf): 12:00 12:00 12:00 <br /> Final Reading(Rf) 11" 101/21, 10" <br /> Test duration(Tf-Ti): 1 hr 1 hr 1 hr <br /> Change in Reading(Rf-Ri): 0 0 0 <br /> Pass/Fail Threshold or Criteria: 0 0 0 0 <br /> Test Results: x Pass Fail x Pass Fail x Pass Fail Pass Fail <br /> Comments-(include information on repairs made prior to testing, and recommended follow-up for failed tests) <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: af— ..,,—..�/� Date: <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 />