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SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This farm is intended jor use by contractors performing annual resting of UST spill containment structures. The completed form <br /> printouts from tests(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency- <br /> 1. <br /> enc <br /> 1. FACILITY INFORMATION <br /> Facility Name: COSTCO a658 Date of Testing: 9!30/08 <br /> Facility Address: 5250 W GRANTLINE RD.,TRACY,CA <br /> Facility Contact: ROBERT Phone: 209 834-1247 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector/jpresent daring testing): MICHELLE HENRY <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: BZ Service Station Maintenance <br /> Technician Conducting Test: JAMES WILLIAMS —--- ---- <br /> Credentials': X CSLB Contractor ServiceTech. ❑S WRCB Tank Tester J Other(Specify) <br /> License Number(s): 433159 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: X Hydrostatic r_1Vacuum ❑Other <br /> Test Equipment Used: BEAKER Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1 87-1 2 87-2 3 91 4 <br /> Number, Stored Product,etc. <br /> ❑Direct Bury ❑Direct Bury 1,1 Direct Bury [I Direct Bray <br /> Bucket Installation Type: X Contained in Sump X Contained in Sump X Contained in Su L'Contained in SUMP <br /> Bucket Diameter: 12 12 12 <br /> Bucket Depth: 16 16 16 <br /> Wait time between applying 0 0 0 <br /> vacuum/water and start of test: <br /> Test Start Time(T,): 11:00 11:00 12:40 <br /> Initial Reading(R,): 525 525 525 <br /> Test End Time(Tr): 12:00 12:00 1:40 <br /> Final Reading(RF): 525 525 525 <br /> Test Duration(Tr—T,): 60 MINS 60 MINS 60 MINS <br /> Change in Reading(Rr—Rj: 0 0 0 <br /> Pass/Fail Threshold or 0 0 0 <br /> Criteria: <br /> Test Result: I X Pass D Fad X Pass D Faj. I,Feil U Pass ❑ Fail <br /> Comments—(include information on repairs made prior to testing and recommended follow-up jor jailed tests) <br /> REPAIRED AND RETESTED THE 91 BUCKET AND IT PASSED <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE F98.CONDUCTING THIS TESTING <br /> /hereby certify tha:agifie info[ on ca ed in this re is[ ac rate,and infullcompliance with legal requirements.Technician's SignatDate <br /> ' 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 />