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P.O.Box 4208 <br /> All techPetr - Sonora 9530 <br /> Ca:623541 A-Haz <br /> Phone:209-5353 2-73220 <br /> Compliance without Compromise Fax:209-533-2650 <br /> nna i 1pal(tech petro.conn <br /> www.alltechpetro.com <br /> Spill Bucket Testing Report Form <br /> FACILITY INFORMATION: <br /> Facility Name: Costco #658 Tracy 77 Date of Testing: September 23, 2015 <br /> Facility Address: 3240 W. Grrant Line Rd Tracy CA <br /> Facility Contact: Tony Haggard Phone: 209-834-1427 <br /> Notification Date of Local Agency: 9/15/2015 <br /> Name of Local Agency Inspector: Garrett Backus <br /> SPILL BUCKET TESTING INFORMATION: <br /> Test Method Used: ® Hydrostatic ❑ vacuum ❑ Other <br /> Test Equipment Used: 1-Hour Observed Test Equipment Resolution: 1/16" <br /> Identify Spill Bucket 1 87A Vapor 2 87B Vapor 3 91 Vapor 4 Additive Aux <br /> Bucket Installation Type: ❑ Direct Bury ❑ Direct Bury Direct Bury ❑ Direct Bury <br /> ® In Sump ® In Sump ® In Sump ® In Sum <br /> Wait time between <br /> applying vacuum/water None None None None <br /> and start of test: <br /> Test Start Time (T,): 8:00 8:00 8:00 8:00 <br /> Initial Reading (R,): 2"Above Cap 2"Above Cap 2"Above Cap 2"Above Cap <br /> Test End Time (T,): 9:00 9:00 9:00 9:00 <br /> Final Reading (Rr): 2"Above Cap 2"Above Cap 2"Above Cap 2"Above Cap <br /> Test Duration (T,—T,): 1.0 Hr. 1.0 Hr. 1.0 Hr. 1.0 Hr. <br /> Change in Reading (R,-R): 0.0 0.0 0.0 0.0 <br /> Pass/Fail Threshold or 1/16" 1/16" 1/16" <br /> Criteria: <br /> Test Result: ® Pass ❑ Fail 1 ® Pass ❑ Fail 1 ® Pass ❑ Fail ® Pass ❑ Fail <br /> Comments - (include information on repairs made prior to testing, and recommended follow-up for failed <br /> tests) <br /> CERTIFICATION 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 <br /> legal requirements. <br /> Technician's Signature: Date: 9/23/15 <br />