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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 comoo//eted form and <br />printouts from tests rd applicable), should be provided to the facility owner/operator for submittal to the local reguietory agency. <br />1. FACILITY INFORMATION <br />Facility Name: Safeway <br />Date of Testing: 1/16/13 <br />Facility Address: 6425 N. Pacific Ave. Stockton, CA 95207 - <br />Facility Contact: Julia Pollick (209) 472-8600 <br />Dale Local Agency Was Notified of Testing: 1/11/13 <br />Name of Local Agency Inspector (if present during testing): Garrett Backus <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name:Service Station Systems <br />Technician Conducting Test: Randy Wilkerson <br />Credentialsi : ® CSLB Contractor ❑X ICC Service Tech. ❑ SWRCB Tank Tester ❑ 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 Resclutlon:1/16 in. <br />Identify Spill Bucket (By rank <br />Number, Stored Product, etc.) <br />1 Fill Bucket <br />01 Re u <br />2 Fill Bucket <br />02 Prem <br />3 Fill Bucket <br />03 Diesel <br />4 <br />Bucket Installation Type: <br />❑ Direct Bury <br />❑X Contained in Sump <br />❑ Direct Bury <br />®Contained in Sump <br />❑ Direct Bury <br />©Contained in Sump <br />E]Direct Bury <br />E] Contained in Sump <br />Bucket Diameter: <br />12.00 in. <br />12.00 in. <br />12.00 in. <br />Bucket Depth: <br />14.00 in. <br />14.00 in. <br />14.00 in. <br />Wait time between applying <br />vacuum/water and start of test: <br />5 min. <br />5 min. <br />5 min. <br />Test start Time R, ): <br />9:30am <br />9:30am <br />9:30am <br />Initial Reading (R, ): <br />13.000 in. <br />13.000 in. <br />13.250 in. <br />Test End Time (TF): <br />10:30am <br />10:30am <br />10:30am <br />Final Reading (Fi ): <br />13.000 in. <br />13.000 in. <br />13.250 in. <br />Test Duration (TF -Tl): <br />1.00 hr. <br />1.00 hr. <br />1.00 hr. <br />Change In Reading (RF • R, ): <br />0.0000 in. <br />0.0000 In. <br />0.0000 in. <br />PasslFailThresholdorCriteria: <br />ZERO LOSS <br />ZERO LOSS <br />ZERO LOSS <br />Test Result: <br />p Pass ❑ Fail <br />[I Pass ❑ Fail <br />® Pass ❑ Fail <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 />thereby certify that alt the fnfomration contained in this report is true, accurate,and in hull compliance with legal requfrements. <br />Technician's <br />1/16)13 <br />t 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 />