Laserfiche WebLink
r <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: SRH I Date of Testing: 5-29-2015 <br /> Facility Address: 749 E CHARTER WAY STOCKTON CA <br /> Facility Contact: JOHNY Phone: <br /> Date Local Agency Was Notified of Testing:5-19-15 <br /> Name of Local Agency Inspector(i(present during testing): STACY JUN 1 $ Z <br /> 2. TESTING CONTRACTOR INFORMATION TAL <br /> Company Name: AFFORDA TEST 4162 n1 Street Galt, CA 95632 (209)744OH � a !�TVe0e1 <br /> 6 <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: h20 and tape measure Equipment Resolution: 1/16 <br /> Identify Spill Bucket(By Tank 1 DSL 2 87 3 91 4 <br /> Number, Stored Product, etc. <br /> ®Direct Bury ® Direct Bury ® Direct Bury El Direct Bury <br /> Bucket Installation Type: ❑ Contained in El Contained in <br /> E]Contained in Sump El Contained in Sump Sump Sum <br /> Bucket Diameter: 11 11 11 <br /> Bucket Depth: 13 13 13 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Td: 9 9 9 <br /> Initial Reading(RI): 12 12.50 12.25 <br /> Test End Time(TF): 10 10 10 <br /> Final Reading(RF): 12 12.50 12.25 <br /> Test Duration(TF—TI): 1 HR IHR IHR <br /> Change in Reading(RF-Rl): 0 0 0 <br /> Pass/Fail Threshold or 1/16 1/16 1/16 <br /> Criteria: <br /> Test Result: ® Pass ❑ Fail E Pass ❑ Fail ® Pass ❑ Fail ❑ Pass ❑ Fail <br /> Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> OPW <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: TC Date 5-29-15 <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 />