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RECEIVED <br />FEB 19 2016 <br />S a OOS <br />Spill Bucket Testing Report Form ENTAL <br />"CAI AS MncaeRTMf=NT <br />This form is intended for use by contractors performing annual testing o/ US7 spill containment structures. The completed form and <br />printouts from tests (if applicable), should be provided to the facility ownerPoperafor for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: Safeway Date of Testing: 01/20/16 <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: 12/22/15 <br />Name of Local Agency Inspector (if present during testing): Fatinah Zareef <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name:Service Station Systems <br />Technician Conducting Test: )iris Bell <br />Credentialst: © CSLB Contractor © ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other (Specify) <br />License Number(s): License:485184 ICC:5297793-UT <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: ® Hydrostatic ❑ vacuum ❑ Other <br />Test Equipment Used: Measuring Tape I Equipment Resolution:1/16 In. <br />Identify Spill Bucket (ay rank <br />Number, Stored Product. etc.) <br />11 Fill Bucket 2 Fill Bucket <br />01 - Re u 02 - Prem <br />3 Fill Bucket <br />03 _= Diesel <br />4 <br />Bucket Installation Type: <br />❑ Direct Bury ❑ Direct Bury <br />❑X Contained in Sump ©Contained in Sump <br />❑ Direct Bury <br />❑X Contained in Sump <br />❑ Direct Bury <br />❑Contained In Sump <br />Bucket Diameter: <br />13.00 in. 13.00 in. <br />13.00 in. <br />Bucket Depth: <br />14.75 in. 14.25 in. <br />14.25 in. <br />Wait time between applying <br />vacuum/water and start of test: <br />10 m10. 10 min. <br />10 min. <br />Test Start Time (Ti ): <br />10:25am 10:25am <br />10:25am <br />Initial Reading (R ): <br />9.750 in. 9.375 in. <br />9.500 in. <br />Test End Time (TF ): <br />11:25am 11:25am <br />11:25am <br />Final Reading (PF ): <br />9.750 in. 9.375 in. <br />9.500 in. <br />Test Duration (TF -Ti): <br />1.00 hr. 1.00 hr. <br />1.00 hr. <br />Change In Reading (RF - R, ): <br />0.000 In. 0.000 in. <br />0.000 in. <br />PasslFail Threshold or criteria: <br />ZERO LOSS ZERO LOSS <br />ZERO LOSS <br />Test Result: <br />p Pass ❑ Fail ® Pass ❑ Fail <br />© Pass ❑Feil <br />❑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 Inf�mauQn coValned in this report Is true, accurate and In full compliance with legal requirements. <br />Technician's <br />Date: 01/20/16 <br />1 Slate laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements <br />may be more stringent. <br />