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6ETTLER-RYAN INC. 'OR 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 ownerloperator for submittal to the local regulatory agency. <br /> Facility Name: Arco'5450 1. FACILITY INFORMATION Date of Testing: <br /> A <br /> Facility Address: 1617" Fremont St.,Stockton <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing: 6/11/2015 Auu—T—Z—z U I j <br /> Name of Local Agency InspeCt-r(ifpresent during-testing): <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: Gettler-Ryan Inc.,6747 Sierra Court Suite J.Dublin,Ca.941568 Ph.#925-551-7555 <br /> Technician Conducting Test: JoeyMesa <br /> Credentials:(1) CSI-B Contractor ]CC service Tech. SWRCB Tank Tester Other(Specify) <br /> License Number: 220793 ICC Tech Number: 5259458-LT <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: Hvdi-ostatic Vacuum Other <br /> Test Equipment Used: Standard Tape Measurer Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By Tank 1 87-1 F=— 87-2 Fill91 Fill 4 <br /> Number,Stored Product,etc. <br /> ]I-- L— I <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, 10.51, 10.51, <br /> Bucket Depth: 14" 14" 14" <br /> Wait time between applying <br /> vacuum/water and start of test: 10ndn 10inin 101nin <br /> Test Start Time(Ti): 11:10 11:10 11:10 <br /> Initial Reading(Ri): 13 318" 13.51, 13 318" <br /> Test End Time(Tf): 12:10 12:10 12.10 <br /> Final Reading(Rf) 13 3/8" 13.5" 13 318" <br /> Test duration(Tf-Ti): Ihr 1 h 1 h <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 I 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 />