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 thefacility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Raleys Date of Testing: 8-4-17 <br /> Facility Address: 4219 Morada In Stockton <br /> Facility Contact: Dawn Phone: 209-956-9300 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(fpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION AUG 18 Z017 <br /> Company Name: Service station systems <br /> Technician Conducting Test: Brian McPheelyr <br /> Credentials: [ICSLB Contractor X ICC Service Tech ❑SWRCB Tank Tester ❑Other pecify) _ <br /> License Number(s): <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: X Hydrostatic ❑Vacuum 0 Other <br /> Test Equipment Used:WATER Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1 87 2 3 4 <br /> Number,Stored Product, etc. <br /> Bucket Installation Type: 0 Direct Bury ❑Direct Bury 0 Direct Bury ❑Direct Bury <br /> X Contained in Sump 0 Contained in Sump ❑Contained in Sump ❑Contained in Sum <br /> Bucket Diameter: 12 <br /> Bucket Depth: 15 <br /> Wait time between applying 5 MIN <br /> vacuum/water and start of test: <br /> Test Start Time(TO: 11:40AM <br /> Initial Reading(Rr): 13% <br /> Test End Time(TF): 12:40PM <br /> Final Reading(RF): 13% <br /> Test Duration(TF—Tr): 60 MIN <br /> Change in Reading(RF-RO: 0 <br /> Pass/Fail Threshold or NO VISUAL <br /> Criteria: <br /> Test Result: X Pass D Fail 0 Pass 0 Fail ❑ Pasa ❑Fail 0 Pass ❑Fail <br /> Comments—(include information on repairs made prior to testing and recommended follow-up for failed tests) <br /> Replaced 87 will bucket outer upper Basket and tested. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the information contained in thjis report is hue,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: ry "1 c. G� �k& f.l, Date:_8-4-17 <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 />