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: ESTES EXPRESS Date of Testing: 05-25-12 <br /> Facility Address: 7611 S AIRPORT WAY STOCKTON CA 95206 <br /> Facility Contact: Phone: 209-982-1841 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(ifpresent during testing): SAN JOAQUIN CO Muni <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 4162 n1 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 I Equipment Resolution: 1/16 <br /> Identify Spill Bucket (By Tank 1 DIESEL 2 3 4 <br /> Number, Stored Product, etc. <br /> ®Direct Bury ❑Direct Bury El Direct Bury ❑Direct Bury <br /> Bucket Installation Type: ❑Contained in Sump El Contained in Sump ❑Contained in El Contained in <br /> SumpSum <br /> Bucket Diameter: 11 <br /> Bucket Depth: 14 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(T,): 900 <br /> Initial Reading(R,): 14 <br /> Test End Time(Tr): 1000 <br /> Final Reading(Rf): 14 <br /> Test Duration(Tr—T,): 1 HOUR <br /> Change in Reading(RF-R,): 0 <br /> Pass/Fail Threshold or PASS <br /> Criteria: <br /> Test Result: ® Pass ❑ Fail ❑ Pass ❑Fail ❑ Pass ❑Fail ❑ Pass ❑ Fail <br /> Comments— (include information on repairs made prior to testing and recommendedfollow-upforfailed 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:05-25-12 <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 />