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GITTLER-RYAN INc. GR Job# 17202618 <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 ownerioperator for submittal to the local regulatory agency. <br /> 1.FACILITY INFORMATION <br /> Facility Name: Arco 5450 Date of Testing: ' 7/2.0/2017 <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 LocalAgency Inspector 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-E'T <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: Hydrostatic Vacuum Other <br /> Test Equipment Used: Standard Tape Measurer Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By Tank 1 87 2 87 3 91 4 <br /> Number,Stored Product,etc.) Vapor ----V-RP-Or Vapor <br /> Bucket Installation Type: Direct Bury Direct Bury Direct Bury Direct Bury <br /> Contained in Sum Contained in Sum Contained in Sump Contained in Sump <br /> Bucket Diameter: 12" 12" 12" <br /> Bucket Depth: 14" 14" 14" <br /> Wait time between applying <br /> 5 Min 5 Min S Min <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 10:30 10:30 10:30 <br /> Initial Reading(Ri): 12" 12" 12" <br /> Test End Time(Tf): 11:30 11:30 11:30 <br /> Final Reading(Rf) 12" 12" 12" <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: InFiST7 Fail P 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 />