Laserfiche WebLink
RECEIVED <br /> FEB 17 2016 <br /> SWRCB,January 2006 <br /> Spill Bucket Testing Report Form ENVIRONMENTAL <br /> !-CRIT n1=14C 01ckm <br /> This loan is intended/or us by contractors pertonning annus/testing of UST sp/11 containment structures. The completed loan and <br /> printouts from tests(if applicable).should be promdetl to the/acility owner/operalor Por submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Safeway Date of Testing:01/19/16 <br /> Facility Address: 2808 Country Club Blvd. Stockton, CA 95204- <br /> Facility contact: Sandra Harbaugh (209)461-5555 <br /> Date Local Agency Was Notified of Testing: 12/22/15 <br /> Name of Local Agency Inspector (i/present during testing): Aris,Veloso <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name:Service Station Systems <br /> Technician Conducting Test: Kris Bell <br /> Credentialst: ®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: ® 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 -Re u 02 -Plus 03-Prem <br /> ❑Direct Bury ❑Direct Bury ❑ Direct Bury ❑Direct Bury <br /> Bucket Installation Type: <br /> �Contained in Sump Contained in Sump © Contained in Sump ❑Contained in Sump <br /> Bucket Diameter: 13.00 in. 13.00 in. 13.00 in. <br /> Bucket Depth: 15.00 in. 15.50 in. 11.50 in. <br /> Wait time between applying <br /> 10 min. 10 min. 10 min. <br /> vacuum/water and start of test: <br /> Test Start Time IT,). 11:27am 11:28am 11:29am <br /> Initial Reading(R,): 14.06 in. 14.25 in. 10.00 in. <br /> Test End Time(TF): 12:27pm 12:28pm 12:29pm <br /> Final Reading(%): 14.06 in. 14.25 in. 10.00 In. <br /> Test Duration(TF-TI): 1.00 hr. 1.00 hr. 1.00 hr. <br /> Change in Reading(RF -R,): 0.000 in. 0.000 in. 0.000 in. <br /> Pass/Fail Threshold or Criteria: ZERO LOSS ZERO LOSS ZERO LOSS <br /> Test Result: ❑X Pass ❑ Fail ❑% Pass ❑Fail ❑X 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 all th7nto <br /> �Id report is true,accurate,and in rut/compliance with legal requirements. <br /> Technician's Signature: Data 01/19/16 <br /> t 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 />