Laserfiche WebLink
Spill Bucket Testin Re ort Form SWRCB, January 2006 <br />9 p JUL 16 2015 <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 owneNoperator for submittal to the local regulatory agency. � yy�1pA (�� //�� <br />ra'i at tlJ'IVIVI�1VTf"1[ <br />1. FACILITY INFORMATION _n1T <br />Facility Name: Safeway Date of Testing: 06/18/15 <br />Facility Address: 1987 W. 11th St. Tracy, CA 95376 - <br />Facility Contact: Will Kaufman (209) 830-2950 <br />Dale Local Agency Was Notified of Testing: 6/1/15 <br />Name of Local Agency Inspector (if present during testing): Michelle <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: Service Station Systems <br />Technician Conducting Test: Kris Bell <br />Credentials . Q CSLB Contractor ❑X ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other (Specify) <br />License Number(s): License: 485184 ICC 5297793 -UT <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: ❑X Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: Measuring Tape Equipment Resolution: 1/16 In. <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />1 Fill Bucket 2 Fill Bucket <br />01 - Re u 02 - Prem <br />3 Fill Bucket 4 <br />03 - Diesel <br />Bucket Installation Type: <br />❑ Direct Bury ❑ Direct Bury <br />❑X Contained in Sump ❑X Contained in Sump <br />❑ Direct Bury E]Direct Bury <br />❑X Contained in Sump ❑ Contained in Sump <br />Bucket Diameter: <br />13.00 in. 13.00 in. <br />13.00 in. <br />Bucket Depth: <br />13.00 in. 13.00 in. <br />13.00 in. <br />Wait time between applying <br />vacuum/water and start of test: <br />10 min. 10 min. <br />10 min. <br />Test Start Time IT, ): <br />11:57am 11:57am <br />11:57am <br />Initial Reading (R, ): <br />12.38 in. 12.88 in. <br />13.00 in. <br />Test End Time (TF ): <br />12:57pm 12:57pm <br />12:57pm <br />Final Reading (Rf ): <br />12.38 in. 12.88 In. <br />13.00 in. <br />Test Duration (TF - T,): <br />1.00 hr. 1.00 hr. <br />1.00 hr. <br />Change in Reading (RF- - R, ): <br />0.000 In. 0.000 In. <br />0.000 In. <br />Pass/Fail Threshold or Criteria: <br />ZERO LOSS ZERO LOSS <br />ZERO LOSS <br />Test Result: <br />Q Pass ❑ Fail Pass ❑ Fail <br />[K Pass ❑ Fail ❑ Pass ❑ Fail <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 />1 hereby certify that all the info n co ained in this report is true, accurate, and in full compliance with legal requirements. <br />Technician's Signature: Date: 06/18/15 <br />t 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 />