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®CIFTTLFR-RYAN INC. „ GR Job# 1820- 1789 <br /> ��v{�� I^�( �..!•�� SWRCB,January 2006 <br /> Spill Bucket T,e m <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.%perator for submittal to the local regulatory agency. <br /> 1.FACILITY INFORMATION <br /> Facility Name: Arco 7149 Date of Testing: 0 6 2 0/2 0ja <br /> Facility Address: 9484 West Late Stockton 95210 <br /> Facility Contact: Daryl Lee Phone: 415-902-5089 <br /> Date Local Agency Was Notified of Testing: <br /> ame of LocalAgency 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(Specify) <br /> License Number: 220793 ICC Tech Number: 8292530 <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: H_drostatic Vacuum Other <br /> Test Equipment Used: Standard Tape Measurer Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By Tank 1 2 3 4 <br /> Number,Stored Product,etc. 87-Product 91-product DSL-product <br /> Bucket Installation Type: Direct Bury LjDirect Bury []Direct Bury []Direct Bury <br /> X Contained in Sump QX Contained in Sump OX Contained in Sump []Contained in Sump <br /> Bucket Diameter: 1411 1411 1411 <br /> Bucket Depth: 1511 1511 15 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> 5 mins 5 mins 5 mins <br /> Test Start Time(Ti): 10 :3 0 10 . 30 10 :3 0 <br /> Initial Reading(Ri): 14" 1411 1411 <br /> Test End Time(Tf): 11:3 0 11 :30 11:30 <br /> Final Reading(RI) 14" 1411 1411 <br /> Test duration(Tf-Ti): 1 hr lhr 1 hr <br /> Change in Reading(Rf-Ri): 0 0 0 <br /> Pass/Fail Threshold or Criteria: 0 0 0 0 <br /> Test Results: ass Mil Pass ElFail PIP... T7 Fail OPOSS Fail <br /> Comments-(include information on repairs made prior to testing,and recommended follow-up for jailed tests) <br /> CERTFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the information contained in this r ort is true,accurate,and in full compliance with legal requirements <br /> Technician's Signature: ZDate: 06/20/2018 <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 />