Laserfiche WebLink
SWRCB, January 2006 <br />Spill Oucket Testing Report Form <br />This form is intended for use by contractors 1 erf rming annual testing of ' UST spill containment structures. The completed form and <br />printouts from tests (f applicable), should be provided to the facility ownerloperator for submittal to the local regulatory agency. <br />1. 1 ACILTTY INFORMATION - <br />Facility Name: Valley Pacific Petr leum I Date of-Festing: 3-14-14 <br />Facility Address: 1524 Fresno Ave., Stockton, CA <br />Facility Contact: Mike Eliason Phone: mm 800-266 <br />Date Local Agency Was Notified of Testing: 3-7-14 _. <br />Name of Local Agency Inspector (rf present ring testingl: Stacev Rivera <br />MAR 31'0 <br />2. TESTING CONTRACTOR INFORMATION <br />_Company Name: Kern County Cuction, Inc. PO Box 6096, Bakersfield, CA 93386EWR0NMMAJ__._ <br />Technician Conducting Test: Josh Si'nons I. FAt-u nCDADTAACRIT <br />Credentials': X CSLB Contractor X IC Service Tech. C SWRCB 'Tank Tester ❑ Other (Specify) <br />License Number(s): 481053 42369 a <br />3. SPILLWUCKET TESTING INFORMATION <br />"rest Method Used XHydrosta 2 Vacuum Other <br />_. <br />Test Equipment Used: Visual Equipment Resolution: .( <br />tdcnttty Spill Bucket t13y T(A 1 I)51 -� 3 4 <br />,Number, Stored Product, etc 1 =: <br />X Direct B �': Direct Bury ; Direct Bury ❑Direct Bury <br />Bucket Installation Type: Contain in Sum 17 Contained in Sum ::::'. Contained in Sum ❑ Contained in Stun <br />Bucket Diameter: <br />Bucket Depth: <br />► ►" I, <br />13" <br />Wait time between applying <br />15 Min. <br />vacuum/water and start of test: <br />-- -- <br />Test Start Time (Ti): <br />9:39 <br />Initial Reading (Ri): <br />7.221 <br />- <br />— <br />Test End Time (Tr): <br />9:54 <br />—Fnal <br />inal Reading (R}): <br />7.221 <br />-- <br />"rest Duration (Tr - Tj): <br />Change to Reading (Rr - Ri): <br />15 Min, <br />0,01, <br />k <br />Pass/FaiI Threshold or <br />0.002" <br />Criteria: <br />- <br />Test Result: <br />X Pass 0 Fail <br />a .Pass © Fail <br />❑ Pass LJ Fail <br />❑ Pass ❑ Fail <br />Comments - (include h!f6rmation on re irs made error as <br />CERTIFICATION OF Tl <br />I hereby certify that all the information <br />Technician's Signature: <br />and recommended follow-up for faded t <br />IAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />d in this report is true, accurate, and In full compliance with legal requirements. <br />Date: 9 -1`I -/y <br />State laws and regulations do not currentlyquire testing to be performed by a qualified contractor. However, local requirements <br />may be more stringent. <br />