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18 2015 <br /> SWRCB.January 2006 <br /> Spill Bucket Testing Report Form XX <br /> This form is intended for use by contractors perfuming annual testing of UST spill containment structures. The completed form and <br /> printouts from tests(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Safeway Date of Testing:01/20/15 <br /> Fatuity address: 2808 Country Club Blvd. Stockton, CA 95204- <br /> Facility Contact: Sandra Harbaugh (209)461-5555 <br /> Date Local Agency Was Notified of Testing: 1/12/15 <br /> Name of Local Agency Inspector (ifpresent during testing): Stacy Rivera <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name:Service Stabon S stems <br /> Technician Conducting Test: Kris Bell <br /> Credentialsi: ®CSLB Contractor ® ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other(Specify) <br /> License Number(s): License:485184 ICC:5297793-UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ❑x Hydrostatic ❑Vacuum ❑ Other <br /> Test Equipment Used: Measuring Tape Equipment Resolution:1/16 in. <br /> Identify Spill Bucket (By Tank 1 Fill Bucket 2 Fill Bucket 3 Fill Bucket 4 <br /> Number, Stored Product etc.) 01 - Re2u 02 - Plus 03 - Prem <br /> ❑ Direct Bury ❑Direct Bury ❑ Direct Bury p Direct Bury <br /> Bucket Installation Type. Contained in Sump <br /> © Contained in Sump ®Containetl in Sump iX] Contained in Sump <br /> Bucket Diameter: 13.00 in. 13.00 in. 13.00 in. <br /> Bucket Depth: 15.00 in. 15.50 in. 12.25 in. <br /> Wait time between applying 5 min. 5 min. 5 min. <br /> vacuumtwater and start of test: <br /> Test Start Time(T,>: 9.38am 10:43am 9:38am <br /> India]Reading(R, ): 13.50 in. 13.38 in. 11.38 in. <br /> Test End Time(TF): 10:38am 11:43am 10:38am <br /> Fina]Reading(R,): 13.50 in. 13.38 in. 11.38 in. <br /> Test Duration(TF-T 1): 1.00 hr. 1.00 hr. 1.00 hr. <br /> Change in Reading(Rr-R,): 0.000 in. 0,000 in. 0.000 <br /> PassrFail Threshold or Criteria: ZERO LOSS ZERO LOSS ZERO LOSS <br /> Test Result: W Pass ❑ Fail ® Pass ❑ Fail © Pass ❑ Fail ❑ Pass ❑ Fail <br /> Comments: Include information on repairs made prior to testing, and recommended follow-up for failed tests. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that alf the In jbigni co lined In this report is true,accurate,and In full compliance with legal requirements. <br /> Technician's Signature: Date 01/20/15 <br /> i 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 />