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SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intended for use by contractors performing annual testing of UST spill containment structures. The completed form and <br /> printouts from tests(if applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Safeway Date of Testing:6/5/12 <br /> Facility Address: 1804 West 11Th. Street Tracy, CA 95376- <br /> Facility Contact: Will Kaufman (209)830-2950 <br /> Date Local Agency Was Notified of Testing: 5/22/12 <br /> Name of Local Agency Inspector (if present during testing): Thuy Tran <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:Service Station Systems <br /> Technician Conducting Test: Randy Wilkerson <br /> Credentialsi: ❑X CSLB Contractor 3) ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other(Specify) <br /> License Number(s): License:485184 ICC:5258560-UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ❑x Hydrostatic ❑Vacuum ❑ Other <br /> Test Equipment Used: Measuring Tape Equipment Resolution:1/16 in. <br /> Identify Spill Bucket (By Tank 1 Fill Bucket 2 Fill Bucket 3 Fill Bucket 4 <br /> /Number, Stored Product,etc.) 01 Re u 02 Prem 03 Diesel <br /> Bucket Installation Type: <br /> ❑ Direct Bury E] Direct Bury ❑ Direct Bury E] Direct Bury <br /> ❑X Contained in Sump ❑x Contained in Sump © Contained in Sump ❑ Contained in Sump <br /> Bucket Diameter: 12.00 in. 12.00 in. 12.00 in. <br /> Bucket Depth: 13.00 in. 13.00 in. 13.00 in. <br /> Wait time between applying <br /> vacuum/water and start of test; 5 min. 5 min. 5 min. <br /> Test Start Time IT, ): 12:00pm 12:00pm 12:00pm <br /> Initial Reading(R, ): 12.375 in. 12.500 in. 13.000 in. <br /> Test End Time(TF ): 1:00pm 1:00pm 1:00pm <br /> Final Reading(RF): 12.375 in. 12.500 in. 13.000 in. <br /> Test Duration(TF-T 1): 1.00 hr. 1.00 hr. 1.00 hr. <br /> Change in Reading(RF -R,): 0.0000 in. 0.0000 in. 0.0000 in. <br /> Pass/Fail Threshold or Criteria: ZERO LOSS ZERO LOSS ZERO LOSS <br /> Test Result: 71 ❑X Pass ❑ Fail X❑ Pass ❑ Fail ❑X Pass ❑ Fail ❑ Pass ❑ Fail <br /> Comments: Include information on repairs made prior to testing, and recommended follow-up for failed 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: 6/5/12 <br /> t 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 />