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ECEIVED <br />FEB 17 2017 <br />SWRCB. japiztigfitx;IV t'NTAL <br />Spill Bucket Testing Report Form j1, nlTl1nFPAFlWENT <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 owner1bgrator for submittal to the local regulatory agency. <br />1 CACTI ITV IkIFf1RMATIf1N <br />Facility Name: Safeway Date of Testing: 01/19/17 <br />Facility Address: 6425 N. Pacific Ave. Stockton, CA 95207 - <br />Facility Contact: Misty Cook (209) 472-8600 <br />Date Local Agency Was Notified of Testing: 12/26/16 <br />Name of Local Agency Inspector (ifpresent during testing): VickiMcCartney <br />O TCCTINr] r nM70AQ7r1R INC1117161ATIfVd <br />company Name: Service Station Systems... <br />Technician conducting Test: Brian MCPheely <br />Credentialsi: © CSLB Contractor © ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other (Specify) <br />License Number(s): Llcense:485184 ICC:8394903-UT <br />3 Soil RICKET TESTING INFORMATION <br />Test Method Used: Z Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: Measuring Tape I Equipment Resolution:1/16 In. <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, efc.) <br />1 Fill Bucket <br />01 - Re u <br />2 Fill Bucket <br />03 - Diesel <br />3 <br />4 <br />Bucket Installation Type: <br />❑ Direct Bury <br />[R] Contained in Sump <br />❑ Direct Bury <br />®Contained in Sump <br />❑ Direct Bury <br />❑Contained In Sump <br />❑ Direct Bury <br />E] Contained in Sump <br />Bucket Diameter: <br />13.00 In. <br />13.00 in. <br />Bucket Depth: <br />13.00 In. <br />14.00 In. <br />Wait time between applying <br />vacuum/water and start of test: <br />5 min. <br />5 min. <br />Test Start rime (T, ): <br />12:22pm <br />12:24pm <br />Initial Reading (R, ): <br />11.500 in. <br />12.750 in. <br />Test End Time (TF ): <br />1:22pm <br />1:24pm <br />Final Reading (PF): <br />11.500 in. <br />12.750 in. <br />Test Duration (TF -T): <br />1.00 hr. <br />1.00 hr. <br />Change in Reading (RF - RI ): <br />0.0000 In. <br />0.0000 in. <br />Pass/Fall Threshold or Criteria: <br />ZERO LOSS <br />ZERO LOSS <br />Test Result: <br />© Pass ❑ Fail <br />❑X Pass [] Fail <br />❑ Pass ❑ Fall <br />❑ Pass ❑ Fail <br />Comments: 91 Fill Failed, will repair, retest and submit results. <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />I hereby certify that all the information contained in this report is true, accurafeand In full compliance with legal requirements. <br />Irk r. - <br />Technician's <br />Date' 01/19/17 <br />1 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 />