Laserfiche WebLink
r' 6ftTtfR-RYAN 11K. Job 20-631616 <br /> F <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 5450 Date of Testing: 7128(? ,15 <br /> Facility Address: 1617 W Fremont St.,Stockton : <br /> Facility Contact: Phone: - <br /> Date Local Agency Was Notified of Testing: 6/11/2015 <br /> ame <br /> of LocalAgency Inspector(if-present during testing): 5 <br /> 2.TESTING CONTRACTOR INFORMATIONE—NVIRONWNTA <br /> Company Name: Gettler-Ryan Inc..6737 Sierra Court Suite J,Dublin,Ca.94568 Ph.#925-551-7555 <br /> Technician Conducting Test: Joey Mesa <br /> Credentials:(1) CSLB Contractor ICC service Tech. SWRCB Tank Tester Other(Spec) <br /> License Number: 220793 ICC Tech Number: 5259458-UT <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: flvdrostatic Vacuum Other <br /> Test Equipment Used: Standard Tape Measurer Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By Tank 1 87-1 Fill 2 87-2 Fill 3 91 Fill 4 <br /> Number,Stored Product,etc. <br /> Bucket Installation Type: Direct Bury Direct Bury Direct Bury Direct Bury <br /> Ji. Contained in Sump X Contained in Sump X Contained in Sump Contained in Sump <br /> Bucket Diameter: 10.51, 10.51° 10.5" <br /> Bucket Depth: 14" 14" 14" <br /> Wait time between applying <br /> IOnein tOmin IQenin <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 11:10 11:10 11:10 <br /> Initial Reading(Ri): 13 318" 13.5" 13 318" <br /> Test End Time(Tf): 12:10 12:10 12:10 <br /> Final Reading(Rf) 13 318" 13.5" 13 3/8" <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: < Date: 7/28/2015 <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 />