Laserfiche WebLink
RECF-DVED <br /> NOV 16 2017 <br /> Spill Bucket Testing Re SWRCB,January 2008 <br /> p 9 t������ENTALH-EALTFi <br /> This form is intended for use by conbactats pertorming annual testing of UST spill containment ��p � feted form and <br /> pdntoufs from tests(i/applicable),should be provided to the facility owner/operator for submitfdHd fhd loco r! egufatf, agency. <br /> 1. FACILITY INFORMATION <br /> FacilityName: Rancho San Miguel Date ofTesting: l0/17/17 <br /> Facility Address: 610 S.Cherokee Ln. Lodi, CA 95240- <br /> Facility Contact: Jesus Jurado (209)33941200 <br /> Date Local Agency Was Notified of Testing: 9/26/17 <br /> Name of Local Agency Inspector (if present during testing): Betty Ho <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name:Service Station Systems... <br /> Technician Conducting Test: Brian MCPheely <br /> Credentialsi: ❑x CSLB Contractor ❑R ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other(Specify) <br /> License Number(s): Limnse:485184 ICC:8394903-UT <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ❑X Hydrostatic ❑Vacuum ❑ Other <br /> Test Equipment Used: Measuring Tape Equipment Resolution:1/16 In. <br /> Identify Spill Bucket (By Tank 1 Fill Bucket 2 Fill Bucket 3 4 <br /> Number,Stated Product,etc.) 01 -Re2u 02-Prem <br /> ❑ <br /> Bucket Installation Type: Direct Bury E] Direct Bury ❑Direct Bury E] Direct Bury <br /> ❑x Contained in Sump ❑X Contained in Sump ❑Contained in Sump ❑ Contained in Sump <br /> Bucket Diameter: 12.00 in. 12.00 in. <br /> Bucket Depth: 13.00 in. 13.00 in. <br /> Wait time between applying <br /> vacuum/water and start of test: 5 min. 5 min. <br /> Test Start Time IT,): 9:45am 9:45am <br /> Initial Reading(R, ): 12.125 in. 11.938 in. <br /> Test End Time(TF): 10:45am 10:45am <br /> Final Reading(PF): 12.125 in. 11.938 in. <br /> Test Duration(TF-T,): 1.00 hr. 1.00 hr. <br /> Change in Reading(RF-R,): 0.0000 in. 0.0000 In. <br /> Pass/Fail Threshold or Criteria: ZERO LOSS ZERO LOSS <br /> Test Result: ®Paas ❑Fail ©Pass ❑ Fail ❑ Pass ❑Fail ❑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 nthe Information contained In this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: C' Data: 10/17/17 <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 />