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RECEIVE C) <br />Spill Bucket Testing Report Form SWR (EBn2,12M, 5 <br />This form is intended for use by contractors performing annual testing o/VST spill containment structures. The MENTAL <br />printouts from tests (if applicable), should be provided to the facility ownedoperator for submittal to the local i CD11CMIChtT <br />1. FACILITY INFORMATION <br />Facility Name: Safeway Date of Testing: 01/22/15 <br />Facility Address: 6425 N. Pacific Ave. Stockton, CA 95207 - <br />Facility Contact: Mist Cook 209 472-8600 <br />Date Local Agency Was Notified of Testing: 1/12/15 <br />Name of Local Agency Inspector (if present during testing): Fatlnah Vareef <br />2- TESTING CONTRACTOR INFORMATION <br />Company Name: Service Station Systems <br />Technician Conducting Test: Randy Wilkerson <br />Credentials: ® CSLB Contractor © ICC Service Tech. ❑ SWRCB Tank Tesler ❑ Other (Specify) <br />License Number(s): License: 485184 ICC:5258560-UT <br />3- SPILL BUCKET TESTING INFORMATION <br />Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: Measuring Tape Equipment Resolution:1/16 in. <br />Identify Spill Bucket (By Tank <br />Number, Stored Product. etc.) <br />1 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 />® 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 />12.00 in. 12-00 in. <br />12.00 In. <br />Bucket Depth: <br />16.50 in, 15.00 in. <br />15.00 in. <br />Wait time between applying <br />vacuum/water and start of test: <br />5 min. 5 min. <br />5 min. <br />Test Start Time IT, ); <br />11:00am 11:00am <br />11:00am <br />Initial Reading (N <br />15.00 in. 14.00 in. <br />14.00 in. <br />Test End Time (TF ): <br />12:00pm 12:00pm <br />12:00pm <br />Final Reading (%): <br />15.00 in. 14.00 In. <br />14.00 In. <br />Test Duration (TF - T I): <br />1.00 hr. 1.00 hr. <br />1.00 hr. <br />Change in Reading (RF - RI ): <br />0.000 In. 0.000 in. <br />0.000 In. <br />Pass/Fall Threshold or Criteria: <br />ZERO LOSS ZERO LOSS <br />ZERO LOSS <br />Test RBSUIY: <br />® Pass ❑ Fail ®Pass ❑Fail <br />®Pass ❑Fail <br />❑Pass ❑Fall <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 Infor;latlon contained in this report is true, accurate,and In full compliance with legal requirements. <br />Technician's <br />Data. 01/22/15 <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 />