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Spill Bucket Testing Report Form SWRCB, January 2006 <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 owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: Safeway Date of Testing: 6/20112 <br />Facility Address: 6425 N. Pacific Ave. Stockton, CA 95207 - <br />Facility contact: Julia Pollick (209) 472-8600 <br />Date Local Agency Was Notified of Testing: / / <br />Name of Local Agency Inspector (rf present during testing): Garrett Backus - <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name:Service Station Systems <br />Technician Conducting Test: M ke Briggs <br />Credentialsi; ❑X CSLB Contractor © ICC Service Tech. ❑ SWRCB Tank Tesler ❑ Other (Specify) <br />License Number(s): License:485184 ICC:8033115-UT <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: I] Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: Measuring Tape <br />Equipment Resolutlon:1/16 In. <br />Identify Spill Bucket (By Tank <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 />E]Direct Bury <br />❑x Contained In Sump <br />❑ Direct Bury <br />❑X Contained In Sump <br />E]Direct Bury <br />❑X Contained in Sump <br />E]Direct Bury <br />❑Contained in Sump <br />Bucket Diameter: <br />11.00 In. <br />11.00 in. <br />11.00 in. <br />Bucket Depth: <br />15.00 in. <br />15.00 in. <br />15.00 in. <br />Wait time between applying <br />vacuum/water and start of test: <br />15 min. <br />15 min. <br />15 min. <br />Test start Time (TI ): <br />10:45am <br />10:45am <br />10:45am <br />Initial Reading (RI ): <br />13.250 in. <br />12.000 in. <br />13.000 in. <br />Test End Time (TF ): <br />11:45am <br />11:45am <br />11:45am <br />Final Reading (RF ): <br />13.250 in. <br />12.000 in. <br />13.000 In. <br />Test Duration IT, -TI): <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 />Pass/Fail Threshold or Criteria: <br />ZERO LOSS <br />ZERO LOSS <br />ZERO LOSS <br />Test Result: <br />0 Pass [j Fail <br />Fx] 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 />I hereby certify that all the Information contained In this report 15 true, accurate,and in full compliance with legal requirements. <br />�r ✓ <br />Technician's Signature: � Date• 6/20/12 <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 />