Laserfiche WebLink
1 <br /> 1. '1 <br /> 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(f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1.FACILITY INFORMATION <br /> Facility Name: PLAZA LIQUOR 2 1 Date of Testing: 03-29-13 <br /> Facility Address: 800 S CHEROKEE LANE LODI CA 95240 <br /> Facility Contact: KAMAL Phone: <br /> Date Local Agency Was Notified of Testing:2-19-13 <br /> Name of Local Agency Inspector(if present during testing): SAN JOAQUIN CO AIRS <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2nd Street Galt, CA 95632 (209)744-0112 Fax: (209)744-0116 <br /> Technician Conducting Test: ❑ Lyle D.Nimmo ❑ Zane A.Nimmo ❑ David A.Winkler ® Felix G. Ramirez <br /> 5249115-UT 5263322-UT 5263373-UT 5273934-UT <br /> Credentials': ®ICC Service Tech. ® SWRCB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br /> Test Equipment Used: TAPE/H2O Equipment Resolution: 1/16 <br /> Identify Spill Bucket(By Tank 1 87 2 91 3 DIE 4 <br /> Number, Stored Product, etc. <br /> ® Direct Bury ® Direct Bury ®Direct Bury E] Direct Bury <br /> Bucket Installation Type: ❑ Contained in ❑Contained in <br /> E] Contained in Sump ElContained in SUMP Sump Sum <br /> Bucket Diameter: 11 11 11 <br /> Bucket Depth: 13 13 12 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Tj): 900 900 900 <br /> Initial Reading(Rj): 12 12 11 <br /> Test End Time(TF): 1000 1000 900 <br /> Final Reading(RF): 12 12 11 <br /> Test Duration(TF—Tj): 1 HOUR 1 HOUR 1 HOUR <br /> Change m Reading(RF-Rj): 0 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: ❑ Pass ❑ 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 the information contained in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: Date:03-29-13 <br /> ' 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 />