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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 owneNoperator for submittal to the local regulatory agency. <br />"Ajr-TOT .�n,F&I:I TIT-, 111][41N <br />Facility Name: Safeway <br />Date of Testing: 1/21/14 <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: 1/3/14 <br />Name of Local Agency Inspector (ifpresent during testing): Stacy Rivera <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: Service Station Systems <br />Technician Conducting Test: Kris Bell <br />Credentialsi: ❑X CSLB Contractor ❑X 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: IM Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used. Measuring Tape Equipment Resolution:1/16 In. <br />Identity 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 />E]Direct Bury ❑ Direct Bury <br />❑X Contained in Sump ©Contained in Sump <br />❑ Direct Bury <br />®Contained in Sump <br />ElDirect Bury <br />❑Contained in Sump <br />Bucket Diameter: <br />12.00 in. 13.00 in. <br />13.00 in. <br />Bucket Depth: <br />16.50 in. 15.00 in. <br />15.00 in. <br />Wait time between applying <br />vacuumtwater and start of test: <br />5 min. 5 min. <br />5 min. <br />Test Start Time IT, ): <br />10:30am 12:17pm <br />12:52pm <br />Initial Reading (R, >: <br />15.000 in. 13.500 in. <br />14.250 in. <br />Test End Time (TF ): <br />11:30am 1:17pm <br />1:52pm <br />Final Reading (Fp ): <br />15.000 in. 13.500 in. <br />14.250 in. <br />Test Duration (TF - TI): <br />1.00 hr. 1.00 hr. <br />1.00 hr. <br />Change in Reading (RF - Ri ): <br />0.0000 In. 0.0000 in. <br />0.0000 in. <br />Pass/Fail Threshold or Criteria: <br />ZERO LOSS ZERO LOSS <br />ZERO LOSS <br />Test Result: <br />® Pass ❑ Fail ®Pass ❑ Fail <br />© Pass. ❑ Fell <br />❑ Pass ❑ Fail <br />Comments: Replaced 87 Fill Cap & Drain, tightened Adapter -Tested & Passed. Return to test w/ Inspector. <br />Tigtened Diesel Fill Drain - Tested & Passed <br />1/28/14 -87 Fill Bucket Tested & Passed w/Inspector <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />I hereby certify that all the information contained In We report Is true, accurateand In full compliance with legal requirements. <br />Technician's Signature: �7 Data. 1/21/14 <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 />