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GETTtER-RYAN INC. Job# 20-631615 <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: 5 <br /> Facility Address: 1617W Fremont St.,Stockton <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing: 6/11/2015 <br /> Name of LocalAgency nspectori present during testing <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: Gettler-Ryan Inc.,6747 Sierra Court Suite 3,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(Specify) <br /> License Number: 220793 ICC Tech Number: 5259458-1;"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 87-1 Vapor 2 87-2 Vapor 3 91 Vapor 4 <br /> Number,Stored Product,etc. <br /> Bucket Installation Type: Direct Bury Direct Bury Direct Bury Direct Bury <br /> X Contained in Sump X Contained in Sump X Contained in Sump Contained in Sump <br /> Bucket Diameter: 10.51° 10.5" 10 5" <br /> Bucket Depth: 14" 14" 140' <br /> Wait time between applying <br /> tUmin lOmin IOrnin <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 12:20 12:20 12:20 <br /> Initial Reading(Ri): 133/81, 13.5" 13 3/8" <br /> Test End Time(Tf): 1:20 1:20 1:20 <br /> Final Reading(Rf) 13 3/8" 13-5" 13 3/8" <br /> Test duration(Tf-Ti): lhr thr Ihr <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 /> 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: t` 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 />