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_ LL. 4L1W 'lli* L_'. <br />JUL 20 201:6 <br />" "No .4 �► <br />SWRCB, Janualy ZDk . ti <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 (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: 06/21/16 <br />Facility Address: 1987 W. 11th St. Tracy, CA 95376 - <br />Facility Contact: Will Kaufman (209) 830-2950 <br />Date Local Agency Was Notified of Testing: 5/20/16 <br />Name of Local Agency Inspector (if present during testing): Stacy Rivera <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: Service Station Systems <br />Technician Conducting Test: Kris Bell <br />Credentials: ❑X CSLB Contractor ❑X 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 <br />Number, Stored Product, etc.) <br />1 Fill Bucket 2 Fill Bucket 3 Fill Bucket <br />01 - Re u 02 - Prem 03 - Diesel <br />4 <br />Bucket Installation Type: <br />F]Direct Bury ❑ Direct Bury ❑ Direct Bury <br />X❑ Contained in Sump ❑X Contained in Sump Contained in Sump <br />E]Direct Bury <br />❑ Contained in Sump <br />Bucket Diameter: <br />13.00 in. 13.00 in. 13.00 in. <br />Bucket Depth: <br />14.00 in. 14.00 in. 14.00 in. <br />Wait time between applying <br />vacuum/water and start of test: <br />10 min. 10 min. 10 min. <br />Test Start Time Ji ): <br />10,30am 10:30am 10:30am <br />Initial Reading (Ri ): <br />13.500 in. 13.000 in. 13.250 in. <br />Test End Time (TF ): <br />11:30am 11:30am 11:30am <br />Final Reading (Rf ): <br />13.500 in. 13.000 in. 13.250 in. <br />Test Duration (TF - T 1): <br />1.00 hr. 1.00 hr. 1.00 hr. <br />Change in Reading (RF - R, ): <br />0.0000 in. 0.0000 in. 0.0000 in. <br />Pass/Fail Threshold or Criteria: <br />ZERO LOSS ZERO LOSS ZERO LOSS <br />Test Result: <br />® Pass ❑ Fail © Pass ❑ Fail ® Pass ❑ Fail <br />❑ 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 the Infer coir talned in this report is true, accurate,and In full compliance with legal requirements. <br />Technician's <br />Date: 06/21/16 <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 />