Laserfiche WebLink
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 owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: Chevron <br />Date of Testing: 5/29/12 <br />Facility Address: 10858 Trinity Pkwy Stockton, CA 95219 - <br />Facility Contact: Manager (209) 952-2213 <br />Date Local Agency Was Notified of Testing: <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 />Credentials: ❑X 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: ❑x Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: Measuring Tape <br />Equipment Resolution:! /16 in. <br />Identify Spill Bucket (By Tank <br />!Number, Stored Product, etc.) <br />1 Fill Bucket <br />01 Re u <br />2 <br />3 <br />4 <br />Bucket Installation Type: <br />E]Direct Bury <br />0 Contained in Sump <br />❑ Direct Bury <br />❑ Contained in Sump <br />E]Direct Bury <br />❑ Contained in Sump <br />❑ Direct Bury <br />❑ Contained in Sump <br />Bucket Diameter: <br />12.00 in. <br />Bucket Depth: <br />14.00 in. <br />Wait time between applying <br />vacuum/water and start of test: <br />5 min. <br />Test Start Time (Ti ): <br />1:30pm <br />Initial Reading (Ri ): <br />13.500 in. <br />Test End Time (TF ): <br />2:30pm <br />Final Reading (F�: ): <br />13.500 in. <br />Test Duration (TF - T 1): <br />1.00 hr. <br />Change in Reading (RF - Ri ): <br />0.0000 in. <br />Pass/Fail Threshold or Criteria: <br />ZERO LOSS <br />Test Result: <br />❑x Pass ❑ Fail <br />❑ 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 />f hereby certify that all the information contained in this report is true, accurate,and in full compliance with legal requirements. <br />Technician's Signature: ��i!�— Date: 5/29/12 <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 />