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SWRCB,January 2006 <br /> Spill BucketTesting Report Form <br /> This form is intended for use by contractors performing annual testing of UST spill containment structures The completed formand <br /> printouts from tests(if applicable),should be provided to the facility ownerloperatorfor submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: ARCO Date of Testing: 10-10-07 <br /> Facility Address: 2430 Joe Pombo Pkwy <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(1fpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: HA4C-Henderson Maint Co <br /> Technician Conducting Test: Clavin William <br /> Credentials]: 0 CS LB Contractor k1CC Service Tech. 11 SWRCBT ank Tester 0 Other(Specify) <br /> License Number(s): 52& S-cj:�f,ej <br /> 14 1 E:A <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: 11 Hydrostatic 0 Vacuum 0,0iher <br /> Test Equipment Used: Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1. T-1 Reg Master 2 T-2 Reg Slave 3.T-3 Sup 4 <br /> Number,Stored Product, etc.) 9 F,11 bt lie <br /> Bucket Installation Type: 0 Direct Bury El Direct Bury El Direct Bury El Direct Bury <br /> kISntained in§jwT El Contained in Suinp 11 Contained in Surnp El Contained in Sump <br /> Bucket Diameter: <br /> Bucket Depth: 5-,® <br /> Wait time between applying <br /> vacuum/water and start of test: r r- <br /> Test Start Time(TO: rj"0 0 <br /> Initial Reading(RI). dill Al <br /> Test End Time(TF): zo 6 <br /> Final Reading(RF): ! i® i 3. 5- <br /> Test Duration(17F—T): Z() <br /> Change in Reading(RF-RO: NIN X Alo e .1 e <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: PlFass 0 Fail [VPass 0 Fail k-frass 0 Fail 0 Pass 0 Fail <br /> Comments— (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> CERTIFICATION OF TECHNICL#*N RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby cerfify that all the informadon contained in this report is trsw,accurate,and infull compliance with legal requirements. <br /> Technician's Signatuxe:.,_ A <br /> L Date: <br /> State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements <br /> mn%T tar M-VfA""A"* <br />