Laserfiche WebLink
• 0 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_fi-om tests (if applicable),should be provided to the facility ownerloperator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: RANCHO SAN MIGUEL Date of Trstin,: 6130110 <br /> Facility Address: 1409 AIRPORT WAY STOCKTON, CA 95205 <br /> Facility Contact: GILBERT Phone: <br /> Date Local Agency Was Notified of Testing:6/3110 <br /> Name of Local Agency Inspector(ifpresent daring testing): RAY VON FLUE <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 211`'Street Galt,CA 95632 (209)744-0112 Fax: (2109) 744-0116 <br /> Technician Conducting Test: ❑ Lyle D.Nimmo 0 Zane A.Nimmo ❑ David A. Winkler ❑ Felix G.Ramirez <br /> 5249115-UT 5263322-UT 5263373-UT 5273934-UT <br /> Credentials': (A ICC Service Tech. ❑ SWRCB Tank Tester <br /> 3. SPILL BUCKETT'EST'ING INFORMATION <br /> Test Method Used: ®Hydrostatic ❑ Vacuum Lj Other <br /> Test Equipment Used: TAPE MEASURE, H2O Equipment Resolution: 1 16" <br /> Identify Spill Bucket(By Tank 1 37 2 89 3 91 4 DIESEL <br /> Number, Stored Product, etc.) <br /> ❑ Direct Bury ❑Direct Bury ❑ Direct Bury ❑ Direct Bury <br /> Bucket Installation Type: Contained in Sump ❑Contained in Sump ® Contained in ❑ Contained in <br /> Sump S U In <br /> Bucket Diameter: 11 11 <br /> Bucket Depth: 15 133/4 <br /> Wait time between applying _ __ <br /> vacuum/water and start of test: <br /> Test Start Time(T(): <br /> 0920 0920 <br /> Initial Reading(R,): <br /> 133/4 117/8 <br /> Test End Time(TF): <br /> 1020 1020 <br /> Final Reading(RF): 133/4 117/8 <br /> Test Duration(TF—Ti): HR HR HR HR <br /> Change in Reading.(RF-R�): 0 0 <br /> Pass/Fail Threshold or _ <br /> Criteria: <br /> Test Result: Z 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:J _ Date: <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 />