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r <br /> RECEIVED 5onoraa CA 95370 <br /> Ca:623541 A-Haz <br /> lite c Pe 6m OCT 7 n1 <br /> iJ 2 U 17 Phone:209-532-7320 <br /> Complionce without Compromise Fax:209-533-2650 <br /> E,`,]N/1P,CN�f s NT,AL mail@alltechpetro.com <br /> 1 : D EPgRTMENT www.ailtechpetro.com <br /> Fill Spill Bucket Testing Report Form <br /> FACILITY INFORMATION: <br /> Facility Name: Costco#658 Tracy Date of Testing: September 21, 2017 <br /> Facility Address: 3240 W. Grrant Line Rd Tracy CA <br /> Facility Contact: Tony Haggard Phone: 209-834-1427 <br /> Notification Date of Local Agency: 9/15/2017 <br /> Name of Local Agency Inspector: John Alaniz <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: <br /> Ll Direct Bury El Direct Bury Ll Direct Bury El Direct Bury <br /> ® In Sump Z.In Sump ® In Sump ® In Sump <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,): 2 1/4 above cap 1 3/4 above cap 2 1/4 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): 2 1/4 above cap 1 3/4 above cap 2 1/4 above cap 2 1/2 above 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 /> 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: Date: 09/21/17 <br />