Laserfiche WebLink
'RECEIVED <br />Spill Bucket Testing Report Form SWRCB,�1)Iu IT'[ 0jU <br />l �Z <br />This form is intended for use by contractors performing annual testing of UST spill containment structures. The ompletteed tt��gd ,MENTAL <br />printouts from tests (if applicable), showld be provided to the facility owner/operator for submittal to the local re ulato At1lJIV <br />1_ FACILITY INFnRMATInN HEALTH DEPARTMENT <br />Facility Name: Safeway Date of Testing: 06/12/18 <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: 5/28118 <br />Name of Local Agency Inspector (if present during testing): Zuna Barker <br />2_ TESTING CnNTRACTnR INFnRMATtnM <br />Company Name: Service Station Systems... <br />Technician Conducting Test: Kris Bell <br />Credentials: © 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: <br />® Hydrostatic <br />❑ Vacuum <br />❑ Other <br />Test Equipment Used: Measuring Tape <br />Equipment Resolution:/ /16 in. <br />Identify Spill Bucket (By Tank <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 />r-1Direct Bury <br />X❑ Contained in Sump <br />E]Direct Bury <br />❑X Contained in Sump <br />❑ Direct Bury E]Direct Bury <br />® Contained in Sump ❑ Contained in Sump <br />Bucket Diameter: <br />14.00 in. <br />14.00 in. <br />14.00 in. <br />Bucket Depth: <br />14.50 in. <br />14.00 in. <br />13.00 in. <br />Wait time between applying <br />vacuum/water and start of test: <br />10 min. <br />10 min. <br />10 min. <br />Test Start Time (T, ): <br />11:49am <br />9:30am <br />9:30am <br />Initial Reading (R, ): <br />11.500 in. <br />13.000 in. <br />13.000 in. <br />Test End Time (TF ): <br />12:49pm <br />10:30am <br />10:30am <br />Final Reading (PF ): <br />11.500 in. <br />13.000 in. <br />13.000 in. <br />Test Duration (TF -T,): <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 />p Pass ❑ Fail <br />© Pass ❑ Fail <br />❑X Pass ❑ Fail ❑ Pass ❑ Fail <br />Comments: 87 Failed. Replaced Gasket - Retested & Passed. <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />I hereby certify that all the Info n co aimed /n this report is true, accurate, and in full compliance with legal requirements. <br />Technician's Signature: Date: 06/12/18 <br />1 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 />