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GFrrajr-RYAN In. GR Job# 1820-1728 <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 (:f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1.FACILITY INFORMATION <br /> a ility Name: Arco 5450 Date of Testing: 7/19/2018 <br /> acitityAddress: 1617 W. Fremont Stockton 95203 <br /> acility Contact: Daryl Lee Phone: 415-902-5089 <br /> ate Local Agency Was Notified of Testing: <br /> ame o gency 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: David Rouse <br /> Credentials:(1) CSLB Contractor ICC service Tech. SWRCB Tank Tester Other(Spec) <br /> License Number: 220793 ICC Tech Number. 8292530 <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Use ill 1,11,smH drostatic Vacuum er <br /> Test Equipment Used: Standard Ta itileasurer Equipment esolution: 1/16" <br /> Identify Spill Bucket y an 1 2 13 4 <br /> Number,StoredProduc etc. 87-Product 87-Product 91-Product <br /> Bucket Installation Type: Bury u;ct Buryerect Bury LjDirectBury <br /> Contained in Sump [@Contained in Sump ©Contained in Sump []Contained in Sump <br /> Bucket Diameter: 12" 1210 1211 <br /> Bucket Depth: 1411 14" 14'1 <br /> Wait time between applying 5 mins 5 mins 5 mins <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 10:50 10 :50 10:50 <br /> Initial Reading(Ri): 12 112 12 1/2 12 1/2 <br /> Test End Time(Tf): 11:50 11:50 11:50 <br /> Final Reading(Rt) 12 1Z2 12 1/2 12 1/2 <br /> Test duration(Tf-Ti): 1 hr 1 hr 1 hr <br /> Change in Reading(Rf-Rii): 0 0 0 <br /> Pass/Fail Threshold or Criteria: 0 0 0 0 <br /> est MOM ass ail r Pssa sit Pass )Faitr3pam Mail <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 containxz:rt is: <br /> s true,accurate,and in full compliance with legal requirements <br /> Technician's Signature: �' Date: 7/19/2018 <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 />