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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 (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: 06/20/17 <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: 5/23/17 <br />Name of Local Agency Inspector (if present during testing): Stacy Riviera <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: ❑X Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: Measuring Tape <br />Equipment Resolution:1/16 in. <br />Identify Spill Bucket (By Tann <br />Number, Stored Product, etc.) <br />1 Fill Bucket <br />01 - Re u <br />2 Fill Bucket <br />02 - Prem <br />3 Fill Bucket 4 <br />03 - Diesel <br />Bucket Installation Type: <br />❑ Direct Bury <br />❑X Contained in Sump <br />E]Direct Bury <br />© Contained in Sump <br />F1Direct Bury E]Direct Bury <br />❑X Contained in Sump ❑ Contained in Sump <br />Bucket Diameter: <br />13.00 in. <br />13.00 in. <br />13.00 in. <br />Bucket Depth: <br />14.00 in. <br />14.00 in. <br />14.00 in. <br />Wait time between applying <br />vacuumhvaterand start of test: <br />10 min. <br />10 min. <br />10 min. <br />Test Start Time (TI ): <br />11:24am <br />11:24am <br />11:24am <br />Initial Reading (R ): <br />13.438 in. <br />13.438 in. <br />13.625 in. <br />Test End Time (TF): <br />12:24pm <br />12:24pm <br />12:24pm <br />Final Reading (RF ): <br />13.438 in. <br />13.438 in. <br />13.625 in. <br />Test Duration (TF -T1): <br />1.00 hr. <br />1.00 hr. <br />1.00 hr. <br />Change in Reading (RF - R, }: <br />0.0000 in. <br />0.0000 in. <br />0.0000 in. <br />Pass/Fail Threshold or Criteria: <br />ZERO LOSS <br />ZERO LOSS <br />ZERO LOSS <br />Test Result: <br />0 Pass ❑ Fail <br />® Pass ❑ Fail <br />® Pass ❑ Fall ❑ Pass ❑ Fall <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 />/hereby certify that all the infn coir talned in this report is true, accurate,and In full compliance with legal requirements. <br />Technician's <br />Date: 06/20/17 <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 />