Laserfiche WebLink
SWRCB,January 2006 <br /> 9. S,.jl Bucket Testing Repol,; orm <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(ifapplicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: CIRCLE K 2701205 Dateof Testing: 10/22/2009 <br /> Facility Address: 16470 CAMBRIDGE @ LOUISE, LATHROP, CA, 95330 <br /> Facility Contact: MANAGER-ROBERT Phone: (209) 858-4116 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): MICHELLE <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: KRISTOPHER BELL <br /> Credentials 1: ❑CSLB Contractor ❑X ICC Service Tech. ❑SWRCB Tank Tester ❑Other(Specify) <br /> License Number: 5297793-ut <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: R Hydrostatic ❑ Vacuum E] Other <br /> Test Equipment Used:TAPE MEASURE Equipment Resolution:NO VISIBLE LOSS <br /> Identify Spill Bucket(By Tank t 1 UNL FILL Z 2 SUP FILL 3 4 <br /> Number,Stored Product, etc) <br /> Bucket Installation Type: ElDirect Bury jj Direct Bury L]Direct Bury ❑Direct Bury <br /> ❑Contained in Sump ❑Contained in Sump ❑Contained in Sump ❑ Contained in Sump <br /> Bucket Diameter: 14" 14-- <br /> Bucket <br /> 4"Bucket Depth: 13" 12-- <br /> Wait <br /> 2"Wait time between applying 1 MIN 1 MIN <br /> vacuum/water and starting test: <br /> Test Start Time(TI ): 8:48 8:48 <br /> Initial Reading(RI ): 1311 12" <br /> Test End Time(TF ): 9:48 9:48 <br /> Final Reading(R F ): 13" 12" <br /> Test Duration: 1 HR 1 HR <br /> Change in Reading(R F-RI ): 0" 0" <br /> Pass/Fail Threshold or 0" 0" <br /> Criteria: <br /> Test Result: M Pass ❑ Fail [xi Pass 1:1 Fail 1:1 Pass D-•-Fail ❑ Pass Fail <br /> Comments - (include in/ornuitimt on repairs made prior to teeing, and reconanended follow-up for failed rc:�nt <br /> CERTIFICATION OF TECIINICIAN 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: 10/22/2009 <br /> i State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements <br />