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• P.O.Box 4208 <br /> AlltechPetr ' swxl ®03 t la@°6 <br /> Phone:209-532-7320 <br /> Compliance without Compromise Fax:209-533-2650 <br /> mail@alltech petro.com <br /> w .alItechpetro.com <br /> Spill Bucket Testing Report Form <br /> 1. FACILITY INFORMATION <br /> Facility Name: Costco #038 Stockton Date of Testing: March 3, 2016 <br /> Facility Address: 1616 Hammer Lane, Stockton CA <br /> Facility Contact: Rick Mederios Phone: 209-478-2040 <br /> Date Local Agency Was Notified of Testing : 2/17/16 <br /> Name of Local Agency Inspector (if present during testing): Fatinah Zareef <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Alltech Petro Inc, P.O. Box 4208, Sonora CA 95370. (209) 532-7320 <br /> Technician Conducting Test: Chad White <br /> Credentials ® CSLB Contractor ® ICC Service Tech. ® SWRCB Tank Tester ❑ Other (Specify) <br /> License Number(s): CSLB CA 623541 A-HAZ, ICC 8152115-UT, SWRCB 09-1747 <br /> 3. 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 (By 1 87A Vapor 2 87B Vapor 3 91 Vapor 4 Additive Vapor <br /> Tank Number, Stored <br /> Product, etc.) <br /> Bucket Installation Type: ❑ Direct Bury El Direct Bury ❑ Direct Bury ❑ Direct Bury <br /> ® In sump In Sump In Sump In Sum <br /> Wait time between <br /> applying vacuum/water 0 0 0 0 <br /> and start of test: <br /> Test Start Time(T): 8:30 8:30 8:30 8:30 <br /> Initial Reading (R,): Top of Cap Top of Cap Top of Cap Top of Cap <br /> Test End Time (TF): 9:30 9:30 9:30 9:30 <br /> Final Reading (RF): Top of Cap Top of Cap Top of Cap Top of Cap <br /> Test Duration (TF—T,): 1.0 Hr. 1.0 Hr. 1.0 Hr. 1.0 Hr. <br /> Change in Reading (RF-R): 0.0 0.0 0.0 0.0 <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 /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the information contained in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: Date: 03/3/16 <br />