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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 comppleted form and <br /> printouts from tests(if applicable),should be provided to the facility owner/operator for submittal to the local regutstory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Safeway Date of Testing:01/18/18 <br /> Facility address: 6425 N. Pacific Ave. Stockton, CA 95207- <br /> Facility Contact: Misty Cook (209)472-8600 <br /> Date Local Agency Was Notified of Testing: 12/22/17 <br /> Name of Local Agency Inspector (if present during testing): Elainna Florido <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name:Service Station Systems... <br /> Technician Conducting Test: Kris Bell <br /> Credentialst: M CSLB Contractor ® ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other(Specify) <br /> License Number(s): Lleense: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 -Prem 03 - Diesel <br /> Bucket Installation Type: E] Direct Bury C] Direct Bury E] Direct Bury ❑ Direct Bury <br /> Q Contained in Sump Q Contained in Sump Q Contained in Sump ❑ Contained In Sump <br /> Bucket Diameter: 13.00 in. 13.00 in. 13.00 in. <br /> Bucket Depth: 14.50 in. 14.00 in. 14.00 in. <br /> Wait time between applying <br /> vacuum/water and start of test: 10 min. 10 min. 10 min. <br /> Test Stan Time(TI): 9:45am 9:45am 10:45am <br /> Initial Reading(RI ): 14.750 in. 13.500 in. 13.250 in. <br /> Test End Time(TF): 10:45am 10:45am 11:45am <br /> Final Reading(FF): 14.750 in. 13.500 in. 13.250 in. <br /> Test Duration(TF-TI): 1.00 hr. 1.00 hr. 1.00 hr. <br /> Change in Reading(RF -R,): 0.0000 In. 0.0000 In. 0.0000 In. <br /> Pass/Fail Threshold or Criteria: ZERO LOSS ZERO LOSS ZERO LOSS <br /> Test Result: ®Pass ❑Fail (K 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 all the Info allDn coWained In this report Is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: Date: 01/18116 <br /> t State laws and regulatlons do not currently require testing to be performed by a qualified contractor.However,local requirements <br /> may be more stringent. <br />