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 the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Safeway Date of Testing:6/2/11 <br /> Facility Address: 1804 West 11 Th. Street Tracy, CA 95376- <br /> Facility contact: Will Kaufman (209)830-2950 <br /> Date Local Agency Was Notified of Testing: 5/24/11 <br /> Name of Local Agency Inspector (if present during testing): <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name:Service Station Systems <br /> Technician Conducting Test: Randy Wilkerson <br /> Credentials: ❑X CSLB Contractor ❑X ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other(Specify) <br /> License Number(s): License:485184 ICC:5258560-UT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ❑X Hydrostatic ❑Vacuum ❑ Other <br /> Test Equipment Used: Measuring Tape Equipment Resolution:)/16 In. <br /> Identify Spill Bucket (By Tank 1 Fill Bucket 2 Fill Bucket 3 Fill Bucket 4 <br /> Number,Stored Product,etc.) 01 Regu 02 Prem 03 Diesel <br /> Bucket Installation Type: E] Direct Bury [jDirect Bury ❑ Direct Bury ❑ Direct Bury <br /> ❑X Contained in Sump ❑x Contained in SumpX❑ Contained in Sump ❑ Contained in Sump <br /> Bucket Diameter: 12.00 in. 12.00 in. 12.00 in. <br /> Bucket Depth: 13.00 in. 13.00 in. 13.00 in. <br /> Wait time between applying <br /> 5 min. 5 min. 5 min. <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 11:35am 11:35am 11:35am <br /> Initial Reading(R, ): 12.000 in. 12.250 in. 12.250 in. <br /> Test End Time(TF): 12:35pm 12:35pm 12:35pm <br /> Final Reading(t�-): 12.000 in. 12.250 in. 12.250 in. <br /> Test Duration(TF-T 1): 1.00 hr. 1.00 hr. 1.00 hr. <br /> Change in Reading(RF-R1): 0.0000 in. 0.0000 in. 0.0000 in. <br /> Pass/Fail Threshold or Criteria: ZERO LOSS ZERO LOSS ZERO LOSS <br /> Test Result: ❑x Pass ❑ Fail ❑X Pass ❑ Fail 1 ❑X Pass ❑ Fail I Pass ❑ Fail <br /> li <br /> Comments: Include information on repairs made prior to testing, and recommended follow-up for failed tests. <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: <br /> 6/2/11 <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 />