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&mien-RYAN IHC. GR Job# 17202518 <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 ownerloperator for submittal to the local regulatory agency. <br /> 1.FACILITY INFORMATION <br /> Facility Name: Arco 5450 Date of Testing: 7/20/2017 <br /> Facility Address: 1617 W Fremont Street,Stockton,CA 95203 <br /> Facility Contact: Daryl Lee Phone: 415,902.5089 <br /> Date Local Agency Was Notified of Testing: " <br /> -Name of Localgencynspector i present during testing) <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: Gettler-Ryan Inc.,6805 Sierra Court,Suite G,Dublin,Ca.94568 Ph.#925-551-7555 <br /> Technician Conducting Test: Gilbert Garcia <br /> Credentials:(1) CSLB Contractor ICC service Tech. SWRCB Tank Tester Other(Specify) <br /> License Number: 220793 ICC Tech Number: 8211864-LFT <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: Hvdrostatic Vacuum Other <br /> Test Equipment Used: Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By Tank I 87 FILL 2 87 Fill 3 91 Fill 4 <br /> Number,Stored Product,etc. <br /> Bucket Installation Type: <br /> Direct Bury Direct Bury Direct Bury Direct Bury <br /> Contained in Sume Contained in Sump <br /> Bucket Diameter: 12" 12" 12" _ <br /> Bucket Depth: 14" 14" 14" <br /> Wait time between applying <br /> S Min 5 Min 5 Min <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 9:00 9:00 9:00 <br /> Initial Reading(Ri): 12 3/8" i t" 11 1/2" <br /> Test End Time(Tf): 10:00 10:00 10:00 <br /> Final Reading(Rf) 12 3/8" 11" 11 1/2" <br /> Test duration(Tf-Ti): 1 hr I hr 1 hr <br /> Change in Reading(Rf-Ri): 0 0 0 <br /> Pass/Fail Threshold or Criteria: 0 0 0 <br /> Test Results: P Faill 51—InA Fail P 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 /> 1 hereby certify that all the information contained in this report is true,accurate,and in full compliance with legal requirements <br /> Technician's Signature: 14�� Date: 7/20/2017 <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 />