Laserfiche WebLink
RECEIVED <br /> SWRCB,January 2006 <br /> Spill Bucket Testing Report Form APR 0 2 2018 <br /> This form is intended far use by contractors performing annual testing of UST spill containment s%ytur,P ted form and <br /> printouts from tests(ifapplicable), should be provided to the facility owner/operator for submitta(Ft�i�'the'Tdc�16% -Pgency. <br /> 9 <br /> 1.FACILITY INFORMATION <br /> Facility Name: GEORGE'S MINI MART Date of Testing: 3-19-18 <br /> Facility Address: 18662 HWY 88 LOCKEFORD,CA 95237 <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(ifpresent during testing): AARON <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 4162 nl Street Galt,CA 95632 (209)744-0112 Fax:(209)744-0116 <br /> Technician Conducting Test: ❑ Ed Stearns ❑ Zane A.Nimmo N David A.Winkler ❑ Felix G.Ramirez <br /> 8883080-UT 8883064-UT 8883059-UT 8883072-UT <br /> Credentials': N ICC Service Tech. N SWRCB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ®Hydrostatic ❑Vacuum ❑Other <br /> 'festEquipment Used: TAPE MEASURE, H2O Equipment Resolution: 1/16" <br /> Identify Spill Bucket (By Tank. 1 87 2 89 3 91 4 DIESEL <br /> Number, Stored Product, etc. <br /> Bucket Installation Type: <br /> ®Direct Bury N Direct Bury N Direct Bury N Direct Bury <br /> ❑ Contained in ❑ Contained in <br /> El Contained in Sump El Contained in Sump SUMP Sum <br /> Bucket Diameter: 11 11 11 11 <br /> Bucket Depth: 14 13 13 1/2 14- <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 9 9 9 9 <br /> Initial Reading(R1): 13 12 13 13 <br /> Test End Time(TF): 10 10 10 10 <br /> Final Reading(RF): 13 12 13 13 <br /> Test Duration(TF—Ti): HR HR HR HR <br /> Change in Reading(RF-Ri): 1 0 0 0 1 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: N Pass ❑ Fail N Pass ❑ Fail N Pass ❑Fail I N Pass ❑ Fail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up forfailed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> 1 hereby certify that all the information <br /> nccontained <br /> �ijn this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature �/ Date:3/19/18 <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 />