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ritz"111j�1 V I -L -o <br />FEB 17 2017 <br />ENVIRONMENTAL <br />HFALTH DEPARTMENT <br />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 ownedoperator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: Safe Way Date of Testing: 02/16/17 <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: / / <br />Name of Local Agency Inspector (dpresent during testing): <br />9 TESTING C7INTRACTPIR INFf1RMATIdN <br />Company Name:Able Maintenance, Inc. <br />Technician Conducting Test: Mike Trejo <br />Credentialst: © CSLB Contractor ❑R ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other (Specify) <br />License Number(s): License: 312844 ICc5252033-UT <br />Q SPIII RI[rKPT TFRTINL` INFr1RMATIAN <br />Test Method Used: ❑X Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: Measuring Tape Equipment Resolution:1/16 in. <br />Identify spill Bucket (By Tenk <br />Number, Stored Product, etc,) <br />1 Fill Bucket <br />02 - Prem <br />2 <br />3 <br />4 <br />Bucket Installation Type: <br />❑ Direct Bury <br />X❑ Contained in Sump <br />❑ Direct Bury <br />E] 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 />Bucket Depth: <br />15.00 In. <br />Wait time between applying <br />vacuum/water and start of test: <br />10 min. <br />Test Start Time (T, ): <br />4:30pm <br />Initial Reading (R, ): <br />11.875 In. <br />Test End Time (TF ): <br />5:30pm <br />Final Reading (FF ): <br />11.875 in. <br />Test Duration CrF - T 1): <br />1.00 hr. <br />Change in Reading (RF - R,): <br />0.0000 In. <br />Pass/Fall Threshold or Criteria: <br />ZERO LOSS <br />Test Result: <br />® Pass ❑ Fail <br />❑Paw ❑ Fail <br />❑ Pass ❑ Fail <br />❑ Pass ❑ Fail <br />Comments: Replaced 91 Fill Bucket <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:, t^` k t Date: 02/16/17 <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 />