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HWEIVEU P.O.Box4208 <br />Sonora CA 95370 <br />ech <br />J�� � ,� �01� Ca: 623541 A-Haz <br />J Phone: 209-532-7320 <br />Compliance without Compromise ENVIRONMENTAL Fax: 209-533-2650 <br />HEA1TN f)``1?ARTPA7NT mail@alltechpetro.com <br />www_ a l l t ec h p et r o. c o m <br />Fill Spill Bucket Testing Report Form <br />FACILITY INFORMATION: <br />Facility Name: Costco # 1031 Manteca Date of Testing: August 19, 2015 <br />Facility Address: 2440 Daniel St. Manteca, Ca <br />Facility Contact: Dave Zizzo Phone: <br />Name of Local Agency Inspector: Jeff Wong <br />SPII I Rl1CKFT TFSTING INFORMATION: <br />Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: 1 -Hour Observed Test <br />Equipment Resolution: 1/16" <br />Identify Spill Bucket <br />1 87A Fill <br />2 87 B Fill <br />3 Premium Fill <br />4 Additive Fill <br />Bucket Installation Type: <br />❑ Direct Bury <br />® In sump <br />❑ Direct Bury <br />❑ In Sump <br />❑ Direct Bury <br />H In sump <br />❑ Direct Bury <br />® In Sum <br />Wait time between <br />applying vacuum/water <br />and start of test: <br />None <br />None <br />None <br />None <br />Test Start Time (T): <br />8:00 am <br />8:00 am <br />8:00 am <br />8:00 am <br />Initial Reading (R): <br />3 1/4" above cap <br />4" above cap <br />4 3/8" above cap <br />1 1/8" above cap <br />Test End Time (TF): <br />9:00 am <br />9:00 am <br />9:00 am <br />9:00 am <br />Final Reading (RF): <br />3 1/4" above cap <br />4" above cap <br />4 3/8" above cap <br />1 1/8" above cap <br />Test Duration (TF — T): <br />1 Hour <br />1 Hour <br />1 Hour <br />1 Hour <br />Change in Reading (RF- R): <br />None <br />None <br />None <br />None <br />Pass/Fail Threshold or <br />Criteria: <br />1/16" <br />1/16" <br />1/16" <br />1/16" <br />Test Result: <br />® Pass ❑ Fail <br />[E Pass ❑ Fail <br />0 Pass ❑ Fail <br />Z Pass ❑ Fail <br />Comments — (include information on repairs made prior to testing, and recommended follow-up for failed <br />tests) <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />1 hereby certify that all the information contained in this report is true, accurate, and in full compliance with <br />legal requirements. <br />Technician's Signature: 4� <br />Date: 08/19/15 <br />