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C1ETTL ER-RYAN INC. GR Job# 1820- 1786 <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 /> Facility Name: Arco 7148 Date of Testing: 06/19/18 <br /> Facility Address: 3400 N. MacArthur Tracy 95376 <br /> Facility Contact: Daryl Lee Phone: 415-902-5089 <br /> Date Local Agency Was Notified of Testing: <br /> Name 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 PhX 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: Hydrostatic Vacuum Other <br /> Test Equipment Used: Standard Tape Measurer Equipment Resolution: 1/16" <br /> Identity Spill Bucket(By Tank l 2 3 4 <br /> Number,Stored Product,etc.) 91-product 87-product DSL-product <br /> Direct Bury []Direct Bury LjDirect Bury Lpirect Bury <br /> Bucket Installation Type: <br /> X Contained in Sump ❑X Contained in Sump ❑X Contained in Sump ❑Contained in Sump <br /> Bucket Diameter: 1011 l 0" loll <br /> Bucket Depth: 10 1/2 10 1/2 10 1/2 <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 : 15 10 : 15 10 : 15 <br /> Initial Reading(Ri): 911 9,1 91, <br /> Test End Time(Tf): 11 : 15 11 : 15 11 : 15 <br /> Final Reading(Rf) 9" 9" 911 <br /> Test duration(Tf-Ti): lhr lhr lhr <br /> Change in Reading(Rf-Ri): 0 0 0 <br /> Pass/Fail Threshold or Criteria: U 11 11 (1 <br /> Test Results: ✓❑Pass ❑Fail ✓❑Pass ❑Fail OPass ❑Fail El Pass El 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 containe this reparl is true,accurate,and in full compliance with legal requirements <br /> Technician's Signature: Date: 06/19/2018 <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 />