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RErNEIV, D P.O.Box 4208 <br /> Sonora CA 95370 <br /> AlltechPetrn Ca 623541 A-Haz <br /> ��G0 2018 Phone:209-532-7320 <br /> Complionce without Compromise Fax:209-533-2650 <br /> ENVIROPJ�►IENTAL <br /> HEALTH DEPARTMENT m mail@alltechpetro.coWWW alltechpetro.com <br /> Fill Spill Bucket Testing Report Form <br /> FACILITY INFORMATION: <br /> Facility Name: Costco # 1031 Manteca Date of Testing: August 14, 2018 <br /> Facility Address: 2440 Daniel St. Manteca, Ca <br /> Facility Contact: Dave Zizzo Phone: <br /> Name of Local Agency Inspector: Aaron Hang <br /> SPILL BUCKET TESTING INFORMATION: <br /> Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br /> Test Equipment Used: 1-Hour Observed Test Equipment Resolution: 1/16" <br /> Identify Spill Bucket 1 87A Fill 2 87B Fill 3 91 Fill 4 Additive Fill <br /> Bucket Installation Type: ❑ Direct Bury ❑ Direct Bury ❑ Direct Bury ❑ Direct Bury <br /> ® In Sump In Sump ® In Sump ® In Sum <br /> Wait time between <br /> applying vacuum/water None None None None <br /> and start of test: <br /> Test Start Time (T,): 9:00 am 9:00 am 9:00 am 9:00 am <br /> Initial Reading (R): 3" above cap 4" above cap 4 3/4" above cap 2 1/2" above cap <br /> Test End Time (TF): 10:00 am 10:00 am 10:00 am 10:00 am <br /> Final Reading (RF): 3" above cap 4" above cap 4 3/4" above cap 2 1/2" above cap <br /> Test Duration (TF—T,): 1 Hour 1 Hour 1 Hour 1 Hour <br /> Change in Reading (RF-R,): None None None None <br /> Pass/Fail Threshold or 1/16" 1/16" 1/16" 1/16" <br /> Criteria: <br /> Test Result: ® Pass ❑ Fail ® Pass ❑ Fail ® Pass ❑ Fail ® Pass ❑ Fail <br /> Comments — (include information on repairs made prior to testing, and recommended follow-up for failed <br /> tests) <br /> I <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> N,;, l hereby certify that all the information contained in this report is true, accurate, and in full compliance with <br /> legal requirements. <br /> �II <br /> �1 <br /> 1 Technician's Signature: Date: 08/14/18 <br />