Laserfiche WebLink
i <br /> - ..J _ LL.raPr.�.'r rV►�-._ <br /> JUL 1 g; B,January 2006 <br /> Spill Bucket Testing Report Form _ <br /> Thisform is intended or use b contractors f'f- y�� •� <br /> .l� f y performing annual testing of UST spill containment,ftg4clasr@s.d@ILcempletedform 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: UNITED GAS I Date of Testing: 6/27/2016 <br /> Facility Address: 3440 E. MAIN STREET STOCKTON, CA 95205 <br /> Facility Contact: Manpreet Phone: <br /> Date Local Agency Was Notified of Testing:6-15-16 <br /> Name of Local Agency Inspector(ifpresent during testing): ARIS V <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 MEASURE, H2O Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By Tank 1 87 2 89 3 91 4 <br /> Number, Stored Product, etc. <br /> ®Direct Bury ®Direct Bury LQ Direct Bury Direct Bury <br /> Bucket Installation Type: ❑Contained in ❑Contained in <br /> ❑Contained in Sump ❑Contained in Sump Sump Sum <br /> Bucket Diameter: 11 11 11 <br /> Bucket Depth: 14 1/2 14 - 13 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Tj): 1305 1305 1305 <br /> Initial Reading(Ri): 13 1/2 13 -- 13 -- <br /> Test End Time(TF): 1405 1405 1405 <br /> Final Reading(RF): 13 1/2 13 -- 13 -- <br /> Test Duration(TF-Ti): HR HR HR <br /> Change in Reading(RF-Ri): 1 0 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: I ® 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 /> ALL BUCKETS MEASURED 5 GALLONS <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:6-27-16 <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 />